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

Effect of facial and nasolabial asymmetry on perceived facial esthetics in children with non-syndromic cleft lip and palate

OBJECTIVE

The aim of the present study was to objectively assess the degree of residual facial asymmetry after primary treatment of non-syndromic unilateral cleft lip and palate (UCLP) in children and to correlate it with subjective ratings of facial appearance.

MATERIALS AND METHODS

Stereophotometry was used to record the faces of 89 children with UCLP for comparison of cleft and non-cleft sides up to 5 years after primary cleft closure. Root mean square values were calculated to measure the difference between the shape of cleft and non-cleft sides of the face and were compared to controls without a cleft lip. The Asher-McDade Aesthetic Index (AMAI) was used for subjective rating of the nasolabial area through 12 laypersons.

RESULTS

Children with a cleft lip (CL) showed no significant difference in RMS values compared to controls. Significant differences occurred when the evaluation was limited to the nasolabial area, however only in patients with cleft lip alveolus (CLA) and cleft lip palate (CLAP)(p < 0.001). In contrast, subjective ratings showed significantly higher values for all three cleft severity groups (CL, CLA, CLAP) compared to controls (p < 0.001). There was a non-linear correlation between the RMS (root mean square) values and the AMAI score.

CONCLUSIONS

Even non-significant discrete objective deviations from facial symmetry in children after primary closure of UCLP are vigilantly registered in subjective ratings and implemented in the judgement of facial appearance.

CLINICAL RELEVANCE

3D stereophotometry is a usefull tool in monitoring asymmetry in patients with a cleft.

Nasolabial appearance in unilateral cleft lip and palate patients: A comparison of aesthetics using two scoring systems: A cross-sectional study

OBJECTIVE

The objective of the study was to assess nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using two scoring systems.

DESIGN

A cross-sectional study conducted in a tertiary care government hospital.

PATIENTS

Photographic records of 91 patients with complete UCL ± P from the age group of 5-18 years (mean age = 13.2 ± 3.14 years) were included.

METHOD

A panel of three orthodontists with varying experience in cleft management rated nasolabial aesthetics using two scoring systems, that is Asher Mc-Dade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Intraclass correlation coefficient, Fleiss' kappa and Cronbach's alpha were used to measure the internal consistency amongst three raters and Spearman-Brown formula was used for measuring overall reliability. Time required for assessment of each photograph was compared with ANOVA.

RESULTS

Overall, both AMAI and CARS showed high reliability and outcome assessment with good inter-rater reliability and internal consistency, when used independently by orthodontists having varied experience. Statistically significant difference was present in time taken for assessment of nasolabial aesthetics with CARS index (8.75 ± 1.65 seconds) as compared to AMAI (18.62 ± 3.49 seconds).

CONCLUSION

Asher Mc-Dade index and CARS are equally reliable and consistent for the assessment of nasolabial aesthetics in patients with UCL ± P. However, considerably less time was taken for the assessment using CARS index as compared to AMAI. The use of CARS index is recommended for the initial assessment and screening of patients by orthodontists using two dimensional photographs.

Three-Dimensional Computed Tomography Reconstruction and Measurement of Nasal End Deformity in Complete Unilateral Cleft Lip and Palate

BACKGROUND

The repair of nasal deformities secondary to cleft lip and palate is complex and requires reliable preoperative nasal 3-dimensional assessment. This study explored nasal end (defined as the lower third of the external nasal and vestibular parts of the nasal cavity) deformities secondary to unilateral complete cleft lip and palate.

METHODS

Three-dimensional nasal end morphometric measurements were obtained from 48 patients who had undergone Millard cleft lip repair and reached skeletal maturity (cleft group) and from 36 age- and ethnicity-matched normal subjects (control group). For the cleft group, paired t tests and 1-way analysis of covariance were used to evaluate the internal and external morphological characteristics of the cleft and noncleft sides of the nasal end, and correlation analysis was done to evaluate the relationship between cleft-side measurements.

RESULTS

In the cleft group, the cleft side showed significantly smaller nasal vestibular volume and skin area, nostril area, nasal column length, and nostril height and greater nostril base length and nasal alar length than the noncleft side (all P < 0.05). Controlling for sex, there were significant differences in the nasal vestibular volume and skin area, internal nasal valve area, long nostril diameter, nostril base length, columella length, nostril height, and nasal alar length between the cleft and control groups (all P < 0.05). On the cleft side, the area of the skin lining of the nasal vestibule positively correlated with the alar length (r = 0.67, P < 0.05).

CONCLUSIONS

Three-dimensional nasal end reconstruction provides a more detailed preoperative nasal end morphological evaluation than previously available techniques.

LEVEL OF EVIDENCE

Level III, case-control study.

Mini-microform cleft lip with complete cleft alveolus and palate: A case report

Cleft lip and cleft alveolus are caused by incomplete fusion of the frontonasal and maxillary prominences. However, milder forms of cleft lip are rarely accompanied by cleft alveolus. Here, we report a rare case of mini-microform cleft lip with complete cleft alveolus and cleft palate. No findings suggestive of cleft lip were evident on initial examination. However, three-dimensional facial measurements confirmed the presence of cleft lip despite no evidence of orbicularis oris muscle (OOM) rupture on ultrasonography. Collapsed nostril, as observed in this case, is usually associated with OOM rupture. However, it can also be caused by skeletal abnormalities, such as cleft alveolus. Three-dimensional facial measurements and ultrasonography can assist in accurate diagnosis when visual examination is ambiguous.

Philtral Ridge Projection in Repaired Unilateral Cleft Lip: Three-Dimensional Anthropometry

BACKGROUND

Cleft surgeons try to construct a philtral ridge during primary repair of a cleft lip, but rarely document the results. The authors used three-dimensional photogrammetry to measure projection of philtral ridges after closure of the common forms of unilateral labial cleft.

METHODS

This is a retrospective study of patients with unilateral complete, incomplete (moderate and severe), and microform cleft lip repaired by one surgeon from 2000 to 2013. Cleft type determined the technique for building a philtral ridge. The relative elevation of the ridge on the cleft versus noncleft side was measured on three-dimensional childhood photographs at two locations along the philtrum: just above the Cupid's bow and at the midlabial level.

RESULTS

Thirty-four patients were evaluated at a mean age of 9.25 years. All cleft types exhibited greater projection at the philtral midlabial level compared with the Cupid's bow level. The authors found a trend toward a more prominent cleft side philtral ridge in microforms. In incomplete cleft lips, there was slightly greater philtral ridge projection in severe forms repaired after a preliminary nasolabial adhesion compared with those repaired in a single stage. There was similar projection of the cleft side ridge in two-stage complete and single-stage repaired incomplete lips.

CONCLUSIONS

It is possible to construct a philtral ridge that is as prominent as the noncleft side in all types of unilateral cleft lip. Increased muscle thickness may explain the slightly increased philtral ridge projection in patients with an incomplete cleft repaired in two stages compared to one-stage closure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Secondary Unilateral Cleft Rhinoplasty Using Natural Curvature of Rib Cartilage as Alar Rim Graft: A Three-Dimensional Evaluation of Long-Term Results

BACKGROUND

Since 2012, the senior author has incorporated the natural curvature of rib cartilage as an alar rim graft in addition to the diced cartilage technique for unilateral cleft rhinoplasty. The aim of this study is to describe this modification and evaluate its long-term results regarding nasal symmetry using three-dimensional stereophotogrammetric assessment (3dMDface system).

METHODS

From 2012 to 2018, 47 consecutive patients that underwent secondary unilateral cleft rhinoplasty were reviewed retrospectively. Sixteen patients with both preoperative and postoperative three-dimensional photographs taken at least 6 months after the operation were included. SimPlant O&O software was used to measure parameters on three-dimensional photographs: nostril heights, nostril widths, nasal dorsum heights, alare width, nostril areas, overlapping nostril area, nasal tip protrusion, nasal length, and nasal height before and after surgery. The ratios between cleft and noncleft sides were calculated. In addition, the overlapping nostril area ratio, tip protrusion-width index, and nasal index were compared before and after surgery.

RESULTS

The preoperative nostril height ratio (0.79), nostril width ratio (1.24), and nasal dome height ratio (0.84) between cleft and noncleft sides were significantly improved after surgery to 0.93, 1.06, and 0.97, respectively. The preoperative overlapping nostril area ratio (72.33 percent), nasal tip protrusion-width index (0.48), and nasal index (0.81) also showed significant improvement postoperatively to 83.91 percent, 0.57, and 0.74, respectively.

CONCLUSION

This preliminary study supports the use of natural curvature of rib cartilage as alar rim graft in secondary unilateral cleft rhinoplasty, with long-term improvement regarding nasal symmetry and nasal profile.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Facial and midfacial symmetry in cleft patients: Comparison to non-cleft children and influence of the primary treatment concept

PURPOSE

Patients with cleft lip, alveolus and palate (CLAP) may suffer from marked asymmetry with an impact on attractiveness and psychosocial aspects. The aim of this study was to assess symmetry in CLAP patients compared to non-cleft controls of similar age with regard to cleft type and treatment concept.

MATERIALS AND METHODS

In CLAP patients with different cleft forms and in healthy non-cleft subjects (control group) a three-dimensional stereophotogrammetric face scan was performed and an objective 3D asymmetry index (AI) was calculated for the whole face, the midface, the upper lip and the nose.

RESULTS

In total, 305 patients were included: 140 CLAP patients (90 male, 50 female, mean age 9.9 ± 3.6 years) and 165 controls (87 male, 78 female, mean age 8.7 ± 2.1 years). In general, CLAP patients showed significantly higher asymmetry than controls, with the most severe asymmetry found in unilateral complete CLAP. Patients treated according to an actual concept considering reconstruction of all affected muscular systems had a significant lower and more favourable AI than patients not treated according to this concept (p < 0.05).

CONCLUSION

An adequate treatment concept is essential to achieve better results concerning symmetry in CLAP, but symmetry values of healthy non-cleft controls are not reached.

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.