Trigonometric method of analysis of the upper part of the mouth cavity

Evaluation of maxillary arch symmetry in cleft patients undergoing orthodontic treatment: a comparative study

OBJECTIVE

Patients with a cleft require structured procedures to achieve feasible treatment results. Since many treatment protocols coexist without being superior to one another, this study investigated the Saarland University Hospital treatment concept for patients with unilateral and bilateral clefts to evaluate its effects upon dental arch dimensions until the early mixed dentition.

MATERIAL AND METHODS

Digitized plaster models were used for data collection. Records of 83 patients (Cleft n = 41 [UCLP n = 28, BCLP n = 13], Non-Cleft Control n = 42) comprised 249 casts. The evaluation included established procedures for measurements of edentulous and dentate jaws. Statistics included Shapiro-Wilk, Friedmann, Wilcoxon and Mann-Whitney-U-Tests for the casts. The level of significance was set at p < 0.05.

RESULTS

The cast analysis showed an approximation of arch dimensions towards those of age-matched patients without a cleft until early mixed dentition. The mean values of patients with and without cleft lip and palate were almost indistinguishable when compared in primary and/or early mixed dentition.

CONCLUSIONS

The evaluated treatment concept leads to feasible outcomes regarding dental arches in patients with unilateral and bilateral clefts compared to an age-matched non-cleft control.

CLINICAL RELEVANCE

The evaluated treatment concept leads to favorable outcomes until early mixed dentition.

Palate Dimensions in Six-Year-Old Children with Unilateral Cleft Lip and Palate: A Six-Center Study on Dental Casts

Objective

To compare palatal dimensions in 6-year-old children with unilateral cleft lip and palate (UCLP) treated by different protocols with those of noncleft children.

Design

Retrospective intercenter outcome study.

Patients

Upper dental casts from 129 children with repaired UCLP and 30 controls were analyzed by the trigonometric method.

Setting

Six European cleft centers.

Main outcome measures

Sagittal, transverse, and vertical dimensions of the palate were observed.

Statistics

Palate variables were analyzed with descriptive methods and nonparametric tests. Regarding several various characteristics measured on a relatively small number of subjects, hierarchical, k-means clustering, and principal component analyses were used.

Results

Mean values of the observed dimensions for five cleft groups differed significantly from the control (p < .05). The group with one-stage closure of the cleft differed significantly from all other cleft groups in most variables (p < .05). Principal component analysis of all 159 cases identified three clusters with specific morphologic characteristics of the palate. A similar number of treated children were classified into each cluster, while all children without clefts were classified in the same cluster. The percentage of treated children from a particular group that fit this cluster ranged from 0% to 70% and increased with age at palatal closure and number of primary surgical procedures.

Conclusion

At 6 years of age, children with stepwise repair and hard palate closure after the age of two more frequently result in palatal dimensions of noncleft control than children with earlier palatal closure and one-stage cleft repair.

Reconstruction of microform cleft lip

Partial cleft of the orbicularis oris muscle without skin and mucosa can also be called "discontinuity of the orbicularis oris muscle" or "subepithelial cleft". Microform cleft lip or mini-cleft lip are better definitions. We present two women aged 25 and 29 years old who complained of vermilion notching, vertical depression on the upper lip, and asymmetry of lower lateral cartilage of the nose. The "discontinuity of the muscle" was found at operation in both cases and reconstructed successfully.

Three-dimensional analysis of morphological changes in the maxilla of patients with cleft lip and palate

OBJECTIVE

Three-dimensional (3-D) morphological changes in the maxilla of patients with cleft lip and palate (CLP) have been recorded, mainly using two-dimensional cast analyses. Although these seem to be insufficient, no standardized 3-D method has been developed until now. In this study, accuracy, precision, and validity of a newly developed 3-D digital computer-aided procedure to visualize and metrically analyze the growth of the edentulous maxilla of infants with CLP have been evaluated.

PATIENTS

The method was applied to 10 infants with complete unilateral CLP.

INTERVENTIONS

Consecutive casts of the maxilla (1 week and 3, 6, and 12 months) of each patient were optically measured with a 3-D laser scanner. Following digitizing, the casts were computer reconstructed, aligned, and superimposed using specialized computer software. The distances between the surfaces were measured. Additionally, the surfaces were segmented perpendicular to the alveolar crest, the reference points being C1, C1', C2, C2', and I. The volumes of the resulting segments were determined and compared with one another.

RESULTS

The newly developed analysis enables a visualization of the extent and direction of morphological changes in the maxilla of infants with CLP. With this method it is possible to quantify these changes of the volume of defined alveolar segments.

CONCLUSIONS

The 3-D analysis developed is an ideal tool for the examination of 3-D morphological changes in the edentulous maxilla of patients with CLP. The results will serve as the starting point for a longitudinal study on the efficacy of different methods, not only of presurgical infant orthopedics but also of surgical procedures.

Characteristic forms of the upper part of the oral cavity in newborns with isolated cleft palate

OBJECTIVE

To determine the functional and morphological compensation of the lack of integrity in the upper part of the oral cavity in newborns with isolated cleft palate. Integrity of the upper part of the oral cavity is required for the effective pumping of amniotic fluid, the essential mode of nutrition in intrauterine life. The adaptation could be seen immediately after birth.

MATERIALS

Plaster casts of the upper part of the oral cavity in 60 newborns with isolated cleft palate of various extent and plaster casts of the upper part of the oral cavity in 27 newborns without cleft were used. A number of surface points were identified and used for a trigonometric morphological analysis.

RESULTS

The parameters of the upper part of the oral cavity in four groups of newborns with various extent of isolated cleft palate were compared with newborns without cleft palate. The results indicate a shift of the functional oral cavity into the nasal cavity and the pharynx, depending on the extent of the cleft.

CONCLUSION

The pumping activity of the tongue forms the upper part of the oral cavity and consequently the tongue moves into the nasal cavity and pharynx, depending on the extent of the cleft. In this way, effective pumping of amniotic fluid is possible despite the cleft. This is of vital importance for the fetus during intrauterine life. A poorly passable or even unpassable respiratory way is only of secondary importance during that time.

The basis for presurgical orthopedic treatment of infants with unilateral complete cleft lip and palate

OBJECTIVE

The purpose of this study was to describe the posttreatment morphology of the upper part of the oral cavity of complete unilateral cleft lip and palate (UCLP) patients and to compare it to noncleft contemporaries. Patients were treated according to a protocol designed to keep a proper resting posture of the oral cavity.

DESIGN

Retrospective study on dental casts.

SETTING

The study was performed at a maxillofacial center serving a population of 2 million inhabitants. Data for noncleft subjects are the result of a longitudinal study at the same institution.

PATIENTS

Twenty-one Caucasian UCLP patients (13 males, 8 females) aged 5 to 9 years with no other congenital anomalies and no postoperative orthodontic treatment.

INTERVENTIONS

Each patient received 5 to 6 months of preoperative orthopedics with a passive plate and external nonelastic strapping with definitive lip repair at age 5 to 7 months, soft palate repair at 11 to 15 months, and hard palate repair with mucoperiosteal closure of the alveolus at 30 to 36 months. Each patient was compared to the mean values obtained from a longitudinal study of a group of 25 healthy noncleft children of the same ethnic group (11 males, 14 females).

RESULTS

Analysis of dental casts indicated that 16 patients had a width, depth, and length of the alveolar arch in the range of the mean normal values minus two standard deviations. Their analyzed palates were flatter than normal. Six of 21 children had too small an alveolar arch for their ages, and they did not acquire a correct posture of the oral cavity.

CONCLUSION

The results indicate that the upper part of the oral cavity of UCLP patients can reach the dimensions of noncleft contemporaries despite surgery.

Changes produced by presurgical orthopedic treatment before cheiloplasty in cleft lip and palate patients

OBJECTIVE

The purpose of this study was to test the hypothesis that, with the use of preoperative treatment, the dimensions of the upper part of the oral cavity of an infant with unilateral cleft lip and palate (UCLP) become more similar to those of a noncleft infant.

DESIGN

This was a retrospective study of upper dental casts taken at birth and prior to lip repair at 6 months of age. A treated group, an untreated group, and a group of noncleft contemporaries were compared cross-sectionally and longitudinally. Models were analyzed by the trigonometric method.

SETTING

The study was performed at a maxillofacial center servicing a population of two million.

PARTICIPANTS

The treated group consisted of 24 babies born after 1990 with UCLP that started presurgical treatment within 20 days of life. The untreated group consisted of 25 randomly selected UCLP casts taken at birth and 25 casts taken just before lip surgery. The noncleft group consisted of 25 full-term infants whose mothers participated in the longitudinal growth study. All participants belonged to the same ethnic group.

INTERVENTIONS

Presurgical treatment consisted of the babies constantly wearing a thin, passive acrylic plate mimicking the normal palate and a slim adhesive tape fixed to the lip segments to bring them slightly together.

RESULTS

The upper oral cavity in a newborn with UCLP was significantly larger than in a noncleft infant, the only exception being in the sagittal dimension. After presurgical treatment, the upper oral cavity was remodeled and slightly enlarged; there was a lesser difference from the noncleft at 6 months than at birth. The cleft in the alveolus reduced significantly, and the position of the incisive point improved. The group without presurgical treatment had no remodeling, and the growth dynamics were similar to the noncleft so that the dimensional differences from the normal remained the same as at birth.

CONCLUSION

The morphological characteristics of the upper part of the mouth change if the functional conditions in the oral cavity are changed. Infants with presurgical orthopedics become more similar to noncleft contemporaries than those without presurgical orthopedics.

New guiding principles in the treatment of clefts

Breathing through the nose with the mouth shut is essential for the normal development of the facial region related to the mouth and nasal cavities and for the normal development of the two cavities named. Surgical treatment of unilateral total cleft practised hitherto calls for the closure of a cleft in the lip and a cleft in the alveolar ridge at the same surgical intervention. In the great majority of cases a combined intervention closes the respiratory pathway, which was established through the cleft nasal floor and alveolar ridge after birth. From the first surgical intervention on, the child is forced to breathe through the mouth. The disruption of the normal functional development mechanism causes the formation of the characteristic physiognomy of a child with a cleft. The correct treatment as presented in this paper, must consistently observe, in addition to other no less important principles, the primary principle: it is essential for a child with cleft to be made to breathe through the nose with the mouth shut, as soon as possible. The operative plan of treatment must help a child with a cleft to create, by utilizing the natural development abilities, and with minimal application of trauma, the same conditions for the functional development mechanism as are possessed by a healthy child of the same age. The enclosed evidence proves the validity of the described guiding rules, and affirms again the well known principle that only normal function produces normal form.

New concept of morphogenesis of clefts in the lip, alveolus, and palate

The morphogenesis of clefts in the lip, alveolus, and palate is a process of both functional and formative adaptation of the affected mouth cavity to the disturbance which the cleft would represent in "pumping" the amniotic fluid. Only a normally developed portal venous system of the foetus, which is a continuation of the digestive canal through the liver, ensures efficient per-oral nutrition after birth. According to the findings known to date, the foetus feeds by "pumping" the amniotic fluid as early as the end of the third month of pregnancy. The amniotic fluid and nutritive substances contained in the fluid, which the foetus receives from the mother through the umbilical vein, are for the greatest part discharged through the foetus's skin. The morphogenesis of clefts proves the formative power of the tongue and its importance in the development of the mouth cavity as well as the ability of the normal growth response of the tissues around the cleft.