Lip and nose morphology in patients with unilateral cleft lip and palate from four Scandinavian centres

Effects of Positioning Errors Onto the Ratio and Angle Measurements in Photographs of Patients With Unilateral Cleft Lip and Palate

BACKGROUND

Nasolabial esthetics is 1 of the most important issues in the evaluation of treatment outcomes in patients with unilateral cleft lip and palate (CLP). Frontal and basal view photographs are commonly used to evaluate nasolabial esthetics in patients with unilateral CLP. High-quality photography plays an important role in evaluating the treatment outcomes and poor quality photographs can result in errors, whereas evaluating the treatment results. Facial proportions and angles are important in the esthetic perception of the face. Hence, this study aimed to determine the effects of positioning errors on the ratio and angle measurements in photographs of patients with unilateral CLP.

METHODS

In the clinical and computer environment, a mechanism was set up to take photos at standard and at different angles. A real-size unilateral CLP silicone doll was constructed for the photographs to be taken in the clinical setting. A test-retest was performed to determine the reliability of the measured values.

RESULTS

The correlation coefficients for the first measurement and remeasurement values were statistically significant; positive and strong correlations were obtained.

CONCLUSIONS

Based on the data obtained from our study, the angle and ratio measurements obtained from the two-dimensional photographs provided reliable results.

Cleft prediction before birth using deep neural network

In developing countries like Pakistan, cleft surgery is expensive for families, and the child also experiences much pain. In this article, we propose a machine learning-based solution to avoid cleft in the mother's womb. The possibility of cleft lip and palate in embryos can be predicted before birth by using the proposed solution. We collected 1000 pregnant female samples from three different hospitals in Lahore, Punjab. A questionnaire has been designed to obtain a variety of data, such as gender, parenting, family history of cleft, the order of birth, the number of children, midwives counseling, miscarriage history, parent smoking, and physician visits. Different cleaning, scaling, and feature selection methods have been applied to the data collected. After selecting the best features from the cleft data, various machine learning algorithms were used, including random forest, k-nearest neighbor, decision tree, support vector machine, and multilayer perceptron. In our implementation, multilayer perceptron is a deep neural network, which yields excellent results for the cleft dataset compared to the other methods. We achieved 92.6% accuracy on test data based on the multilayer perceptron model. Our promising results of predictions would help to fight future clefts for children who would have cleft.

Reliability of Measurements on Plaster and Digital Models of Patients with a Cleft Lip and Palate

Objective

The purpose of this study was to determine (1) the more and less reliable measurements/methods and (2) the influence of knowledge and skill on the inter-examiner, intra-examiner, and inter-method reliability of nasolabial measurements on plaster casts and three dimensional (3D) stereophotogrammetric images of casts in infants with an unrepaired unilateral cleft lip and palate (UUCLP).

Methods

Preoperative extraoral plaster casts from 42 patients with UUCLP were measured with a digital caliper, and the image acquisition of casts was performed with the 3dMDface stereophotogrammetry system (3dMD, Atlanta, GA). Two examiners (one postgraduate student, one lecturer) evaluated 19 nasolabial measurements in two separate sessions.

Results

Intra-rater, inter-rater, and inter-method reliability was lower in measurements of nasal, philtral, and nasal floor width. Almost all of the interclass correlation coefficients (ICC) for measurements performed by the lecturer were above 0.75, whereas the intra-examiner reliability of some measurements performed by the postgraduate student showed low ICC (<0.75).

Conclusion

Measurements of curving slopes, such as nasal width, of small dimensions, such as nostril floor width, and deformity-affected anatomic parts, such as philtrum width, presented a low reliability. Measurements on 3D images showed a higher reliability compared to plaster model measurements performed by the postgraduate student. Therefore, it may be recommended to use 3D digital images of infants with CLP for nasolabial measurements especially if performed in postgraduate settings.

Strategies to Evaluate Bilateral Cleft Lip Treatment

OBJECTIVE

Evaluate treatment of patients with bilateral cleft lip operated during the last 10 years, using the methodology of Mortier and Anastassov.

METHODS

A total of 84 patients were evaluated using a preoperative score assessing fissure severity and a postsurgical score assessing of uncorrected or secondary deformities. A pre- and postcorrelation analysis was performed to evaluate the gain and identify the main postoperative alterations, using Spearman's statistical test (P < 0.001).

RESULTS

About 89.3% underwent surgery between 4 and 7 months. Surgical techniques used Millard 65.5% and Mulliken 34.5%. Presurgical evaluation classified fissures as mild (0%), moderate (2.4%), severe (19.1%), or very severe (78.6%). Postoperative evaluation classified results as poor (24%), satisfactory (12%), good (15, 6%), very good (34.6%), or excellent (14.3%). The postoperative changes on the lip were the notch in the vermilion and the defect in the edge of the vermilion, and in the bow of the wide cupid; in the nose, the most frequent were deficiency in the upper nasal nostril, insufficient rotation of the alar base, broad tip, and short columella; in the scar and alveolar portion, the most frequent were alveolar cleft, premaxilla protrusion, and poor scar. Spearman correlation of preoperative and postoperative was positive of 0.43.

CONCLUSION

The proposed measurement method is technically simple and can be performed without equipment allowing pre- and postoperative evaluation to identify the main alterations to be corrected.

Nasolabial Morphology Following Nasoalveolar Molding in Infants With Unilateral Cleft Lip and Palate

AIM

The aim of the present study is to evaluate the effects of nasoalveolar molding (NAM) therapy on nasolabial morphology three dimensionally, and compare the nasolabial linear and surface distance measurements in infants with unilateral cleft lip and palate.

METHODS

Facial plaster casts of 42 infants with unilateral cleft lip and palate taken at the onset (pre-NAM) and finishing stage (post-NAM) of NAM were scanned with 3dMDface stereophotogrammetry system (3dMD, Atlanta, GA). Nineteen nasolabial linear and surface distance measurements were performed on three-dimensional images. In addition to standard descriptive statistical calculations (means and SDs), pre- and post-NAM measurements were evaluated by paired t test.

RESULTS

All measurements except lip gap, nostril floor width, and nostril diameter increased between pre-NAM and post-NAM. Nostril and lip height increased significantly on the cleft side (P < 0.05). No differences were present between linear and surface distance measurements except for nasal width measurement.

CONCLUSIONS

Nasal and lip symmetry improved with NAM. The use of surface distance measurements may be advised particularly for continuous and curved anatomic structures in which circumference differences are expected.

Comparison of the Basal View and a Previously Standardized Cleft Lip Rating Scale

OBJECTIVES

Numerous scales assessing the aesthetics of cleft lip repair exist. Most, including the Asher-McDade scale, use frontal and lateral views, while neglecting a basal view. We believe this view is important for properly assessing the aesthetics of repair. In this study, we evaluate the basal view in comparison to the Asher-McDade scale.

METHODS

This scale was based on progressive columellar shortening and alar flaring/slumping. A panel of 4 plastic surgeons applied the basal and Asher-McDade scales to pictures of patients with repaired unilateral cleft lip in 56 multiethnic participants aged 5 years to 18 years; images were scored from 1 to 5 (best). Statistical analysis was done via Spearman correlation.

RESULTS

Scores from plastic surgeons correlated strongly for each view. There was moderate correlation for the basal view with both nasal form and deviation scores ( P < .05). As expected, there were no strong correlations between the basal view and vermillion border or profile.

DISCUSSION

The Asher-McDade scale has been used to evaluate cleft lift repairs but is limited due to its subjective nature. The basal view scale grades these repairs by using a scale of progressive columellar shortening and alar flaring/slumping, which provides an opportunity for quantification and standardization. Our results show that the basal view correlates with the Asher-McDade scale among raters, thus providing an objective and validated measure of cleft lip repair.

A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project.

METHOD

Ten established national or regional cleft centres participated. Lip and soft palate closure at 3-4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3-4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3-4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes.

RESULTS

Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years.

CONCLUSION

The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series.

TRIAL REGISTRATION

ISRCTN29932826.

The Eurocleft Study: Intercenter Study of Treatment Outcome in Patients with Complete Cleft Lip and Palate. Part 5: Discussion and Conclusions

Objective

To review the lessons learned from a longitudinal intercenter comparison study.

Design

Longitudinal cohort study.

Setting

Multidisciplinary cleft services in Northern Europe.

Subjects

Individuals with repaired complete unilateral cleft lip and palate.

Main Outcomes Measures

The first four papers in this series report amount of treatment, cephalometric form, nasolabial appearance, dental arch relationship, patient/parent satisfaction. This paper considers the consistency of outcome at the five centers over time, and other relationships between outcomes.

Results

Some outcomes measured in childhood can be predictive over time. The amount of treatment does not correlate with the quality of clinical outcome.

Conclusions

Measurement of clinical outcome in childhood is an important and valid form of clinical audit. Intercenter studies are more informative than single center reports, and will have an important future role in cleft care.

Comparison of Oxygen Saturation During Impression Taking Before and After Presurgical Orthopedic Therapy in Babies With Cleft Lip and Palate

AIM

The objective of this study was to (1) evaluate the oxygen saturation (SpO₂) levels during intraoral and extraoral impression taking and (2) compare the SpO₂ levels during impression taking before and after presurgical orthopedic therapy (POT) of infants with cleft lip and palate (CLP).

PATIENTS AND METHODS

In our study, 31 babies with CLP before (mean age 7.6 ± 3.2 days) and after (mean age 108.3 ± 24.2 days) POT were monitored, and SpO₂ levels were measured under operating conditions before any intervention (T1), after oxygenation (T2), during taking intraoral (T3), and extraoral (T4) impressions with oxygen support and immediately before the discharge from the operating room (T5).

RESULTS

In both groups, statistically significant differences in SpO₂ measurements at T1, T2, T3, T4, and T5 stages were found (P < .01). For the pre-POT measurements, increases in SpO₂ levels from T1 to T2 and T4 to T5 (P < .05) and decreases from T2 to T3 and T3 to T4 (P < .01) were noted. Similarly, SpO₂ levels decreased significantly from the intraoral (T3) to extraoral (T4) post-POT impression periods (P < .01). Comparisons of pre- and post-POT measurements revealed that the SpO₂ level of each time period was higher at the post-POT impression taking except for stages T2 and T5 (P < .01).

CONCLUSION

The SpO₂ values were low at the onset of POT in infants with CLP before any intervention. Oxygen saturation levels may decrease particularly during extraoral impression taking in infants with CLP despite the supplemental oxygen. SpO₂ measurements were higher during post-POT intraoral and extraoral impression taking when compared with pre-POT measurements.

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.

Nasolabial appearance after two palatoplasty types in cleft lip and palate

BACKGROUND

Facial appearance is important for normal psychosocial development in children with cleft lip and palate (CLP). There is conflicting evidence on how deficient maxillary growth may affect nasolabial esthetics.

METHODS

We retrospectively investigated nasolabial appearance in two groups, the Langenback (35 children; mean age 11.1 years; range: 7.9-13.6) and Vomerplasty (58 children; mean age 10.8 years; range: 7.8-14), who received unilateral CLP surgery by the same surgeon. The hard palate repair technique differed between the two groups. In the Langenback group, palatal bone on the non-cleft side only was left denuded, inducing scar formation and inhibiting maxillary growth. In the Vomerplasty group, a vomerplasty with tight closure of the soft tissues on the palate was applied. Thirteen lay judges rated nasolabial esthetics on photographs using a modified Asher-McDade's index.

RESULTS

Nasolabial esthetics in both groups was comparable (p > 0.1 for each nasolabial component). Inferior view was judged as the least esthetic component and demonstrated mean scores 3.18 (SD = 0.63) and 3.13 (SD = 0.47) in the Langenback and Vomerplasty groups, respectively. Mean scores for other components were from 2.52 (SD = 0.63) to 2.81 (SD = 0.62). Regression analysis showed that vomerplasty is related with slight improvement in the nasal profile only (coefficient B = -0.287; p = 0.043; R(2 ) = 0.096).

CONCLUSIONS

This study demonstrates that the use of vomerplasty instead of the Langenbeck technique is weakly associated with the nasolabial appearance among pre-adolescent patients with UCLP.

The parameters of care for cleft lip and palate patients in Aarhus, Denmark

Aarhus Cleft Palate Institute receives approximately 75 new cleft patients a year. Due to statuary notification of all newborn cleft patients to the Institute, the treatment protocol can be offered to the family from right after birth, and a coordinated team approach can be established. The individually planned primary surgery, speech and growth of the maxillo-facial skeleton is followed by regular team examinations. Speech development is followed from the child is one year old in order to be able to provide speech assessment as soon as problems of hypernasality and articulation disorders or language delay is evident. One of the goals of speech assessment is to achieve acceptable speech as early as possible and at best before school start. Orthodontic treatment is usually started at 8 years of age, in UCLP and BCLP patients in combination with bonegrafting at 9-11 years of age. In patients with impaired growth of the maxilla, attention is paid to identify candidates for orthognathic surgical treatment as early as possible. All secondary surgical treatment on jaws, lips and nose are coordinated and usually the treatment can be finished by the late teens. The described team approach towards the parameters of care for cleft lip and palate patients has basically been used for more than 50 years. A systematic follow-up and data collection on all patients provide a scientific base for evaluation of treatment results. Based on long-term investigations the protocol has gradually been modified during time to improve the quality of patient care.

Cephalometric outcome of two types of palatoplasty in complete unilateral cleft lip and palate

In complete unilateral cleft lip and palate (CLP), a vomerplasty is assumed to improve midfacial growth because of the reduction in scarring in the growth-sensitive areas of the palate. Our aim, therefore, was to evaluate maxillofacial morphology after a modified Langenbeck technique or a vomerplasty in children with complete unilateral CLP who were operated on by a single surgeon. As part of a one-stage closure of complete unilateral CLP done during the first year of life, the technique for repair of the hard palate repair differed between the two groups. In the modified group (n=37, mean age 11 years) a modified von Langenbeck technique was used that resulted in denudation of the bony surface on the non-cleft side only. In the vomerplasty group (n=37, mean age 11 years) a vomerplasty was used to cover the palatal bone. Lateral cephalograms from both groups were compared using the Eurocleft protocol. Fourteen angular variables were measured and 2 ratios calculated. Skeletal morphology in the groups was comparable. Maxillary incisor inclination (ILs/NL angle) and interincisal angle (ILs/ILi) were better after vomerplasty (p=0.001 and 0.04, respectively) but soft tissue facial convexity (gs-prn-pgs) was less good after vomerplasty (p=0.009). However, there was no difference between the groups in the other variable that reflected facial convexity (gs-sn-pgs) (p=0.22). Modification of the palatoplasty had a limited effect on skeletal morphology in preadolescent children, but it resulted in better inclination of the maxillary incisors.

Nasal changes after presurgical nasoalveolar molding (PNAM) in the unilateral cleft lip nose

PURPOSE

Nasal reconstruction for patients with unilateral cleft lip and palate (UCLP) is a challenge for the reconstructive surgeon. Presurgical nasoalveolar molding (PNAM) was introduced to reshape the cleft nasal structures prior to lip repair. This study analyzed two-dimensional nasal changes before and after PNAM in patients with complete UCLP.

METHODS

Thirty UCLP patients (19 males; 11 females) who received PNAM before lip repair were included in this study. PNAM was applied for 100 days. Nasal casts were obtained before and after PNAM. Frontal and 45° standardized digital photographs were taken from all casts, and a photogrammetric analysis (16 linear, six angular, and two area measurements) was performed. Paired Student's t tests were used to search for differences by time, and time versus side (cleft versus noncleft).

RESULTS

Significant reduction of cleft columella deviation with an increase in columella length, nostril height, and axial inclination on the cleft side were recorded. This resulted in an increase in the projection of the nasal tip. The noncleft measurements remained without significant changes. The cleft nostril area increased significantly more than the noncleft side by 90% with PNAM treatment. Significant normal growth changes were observed in nasal width and nasal height.

CONCLUSION

A favorable reshaping of the nose after PNAM was achieved, resulting in an improvement in form before lip surgery. These changes lead to improved nasal symmetry before primary lip and nasal reconstruction in UCLP patients.

Comparison of facial soft tissue measurements on three-dimensional images and models obtained with different methods

AIM

The aim of this study was to compare the clinical facial soft tissue measurements with the measurements of facial plaster cast, three-dimensional scanned facial plaster cast, 3-dimensional digital photogrammetrical images, and three-dimensional laser scanner images.

MATERIALS AND METHODS

Three-dimensional facial images of 15 adults were obtained with stereophotogrammetry and a three-dimensional laser scanner. Facial models of subjects were obtained using silicone impression and were scanned. Landmarks were marked on the subjects and plaster casts, digitized on three-dimensional models, and measured in Mimics 12.0 software (Materialise's Interactive Medical Image Control System, Leuven, Belgium).

RESULTS

No statistically significant differences were found between all three-dimensional measurement methods in mouth width, philtrum median height, and nasal width. Comparison of clinical measurements with facial plaster cast measurements revealed that philtral width, nasal tip protrusion, and right lip and nostril heights were wider and longer in clinical measurements than in facial plaster cast measurements. Comparison of clinical measurements to the laser scanned and stereophotogrammetric model measurements revealed that philtrum lateral and lip heights and philtral width were significantly different between methods. When laser scanned and stereophotogrammetric measurements were compared, significant differences were observed in lip and nostril heights.

CONCLUSIONS

Facial impression may be problematic owing to the depression caused by the impression material especially on the tip of the nose. Laser scanning is not sensitive enough to visualize the deeper indentations such as nostrils. Stereophotogrammetry is promising for three-dimensional facial measurements and even will be better when color identification between mucocutaneous junctions of the lip region is achieved.

110 infants with unrepaired unilateral cleft lip: An anthropometric analysis of the lip and nasal deformities

The aim of this retrospective study was to correlate the width of the cleft lip with the severity of the nasal deformity in unilateral cleft lip and palate (UCLP) patients before primary lip repair. Preoperative impression casts were made. Measurements were taken of the width of the cleft lip (CW), nose (NW), and nasal floor (NFW), alar base height (ABH), columella length (CL), nasal length (NL) and nasal tip protrusion (NTP). The ratio of the non-cleft side (NFW) to the cleft side (NFWR), the ratio of the non-cleft side (ABH) to the cleft side (ABHR), and the ratio of the cleft side (CL) to the non-cleft side (CLR) were calculated. The average NW, NL and CW were higher in the group with complete clefts. There was a negative linear relationship between CW and NFWR, and a positive linear relationship between CW and ABHR in the complete group. In the incomplete group, negative correlations were obtained between CW and NFWR and between CW and ABHR. These findings show that there are correlations between CW and the transverse and vertical imbalance of nose in both groups but not between CW and anteroposterior imbalance of nose.

Correlation between facial morphology and esthetics in patients with repaired complete unilateral cleft lip and palate

OBJECTIVE

The purpose of this study was to determine if there were correlations between anthropometric nasolabial measurements and subjective assessments of nasal esthetics in individuals with repaired complete unilateral cleft lip and palate (CUCLP).

PARTICIPANTS

The sample consisted of 28 individuals with repaired CUCLP and 20 age- and gender-matched individuals without clefts.

OUTCOME MEASURES

Nasolabial morphology was assessed using 2D and 3D measurements made on frontal photographs, lateral cephalometric radiographs, and plaster nose casts. A panel of orthodontists rated nasal esthetics from frontal, lateral, three-quarter, and basal view photographs and plaster nose casts using visual analog scales, and they also order ranked the nose casts. Based on the nasal esthetics ratings and rankings, two groups that had the best and the worst esthetics representing the extremes of nasolabial esthetics were statistically identified. Measurements were compared between the cleft and noncleft and the best and worst groups using t tests and analysis of variance.

RESULTS

Differences in anthropometric measurements between the groups were identified. The columellar width and nose base and nasolabial angles significantly differed between the best and worst groups (p < .05). Differences in panel ratings of nasolabial esthetics between the best and worst groups were statistically detected using lateral and three-quarter view photographs (p < .05).

CONCLUSIONS

Although morphologic differences between the cleft and noncleft and between the best and worst groups were identified, the slight morphologic differences noted were not sufficient to explain the subjective esthetic evaluation by the panel.

Changes in lip 1 year after modified Millard repair

The aim of this study was to observe changes in the lip 1 year after performing a modified Millard cleft lip repair, by comparing the preoperative and 1-year follow-up appearance of the lip. Twenty-three patients with a unilateral complete cleft were photographed by a standardized method before repair, 7 days after surgery and 12 months after surgery. Lips on the cleft side were measured and compared with the opposite side. Possible results were: equal, longer and shorter. There was no linear correlation between the preoperative and 1-year postoperative appearance of the lip, but there was a linear correlation in lip height between the 7-day and 12-month postoperative results. No matter how severe the initial deformity, primary repair of the cleft lip is crucial in maintaining labial symmetry 1 year after operation.

Study of changes in nasal morphology in children with complete unilateral cleft lip and palate after secondary bone grafting measured with image analysis

We aimed to evaluate retrospectively changes in the nasal appearance after secondary bone grafting in children with complete unilateral cleft lip and palate in 41 consecutive patients. Basal view photographs were analysed by a software program (ASYMNOS, for asymmetry of nostrils, available on simple request) that computes comparative functions between both nostrils and gives an objective score. These data were compared with those of a control group. The measurements and scores were calculated for each group, and then the global objective scores were correlated with the subjective scores that resulted from an independent external panel that ranked the aesthetic aspects of the nostrils. There was a significant improvement in the nasal symmetry postoperatively that resulted from a decrease in height between the nostrils, and a positive correlation between the objective and subjective scores.

The anthropometric verification of corrective surgery outcome in cleft secondary deformities

An anthropometric measurement serves as both an objective assessment and a description of shape and size. Gypsum casts were used for the measurement, along with a statistical evaluation of results, to compare the appearance of patients with a complete unilateral or bilateral cleft lip and palate prior to corrective surgery of their secondary deformity and following this intervention. The evaluated approach was our own modification of rhinoplasty and lip correction, using the remodeling and extension of soft tissues envelope by a skin flap. That is formed from a lip scar after primary reconstruction. Both data of the studied group (n = 49), pre- and postoperative, were compared to a control group of healthy individuals (k = 19), thereby allowing the original severity of the deformity and the morphologic change after surgery to be objectively assessed. Upon correlation to healthy volunteers, we proved that the effect of surgery shifted the monitored parameters into a range found in the normal population. An anthropometric measurement on gypsum casts appeared to be simple, easy to perform, precise, easy to repeat, inexpensive, and yet of a three-dimensional nature with no burden for the patient. It is suitable for verifying the effects of new therapeutic procedures.

The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 2: craniofacial form and nasolabial appearance

OBJECTIVE

To compare craniofacial morphology and nasolabial appearance up to age 17 in individuals with repaired complete unilateral cleft lip and palate (UCLP) treated at five European centers.

DESIGN

Longitudinal cohort study.

SETTING

Multidisciplinary cleft services in Northern Europe.

SUBJECTS

127 consecutively treated individuals with repaired complete UCLP.

MAIN OUTCOME MEASURES

Cephalometric variables, 14 angular and 2 ratio variables, and panel ratings of nasolabial appearance, 4 variables.

RESULTS

The results revealed that at ages 12 and 17, two centers had a flatter profile (gs-sn-pgs) and retrognathic maxilla (sss-ns-sms). Additionally, one of the two centers had increased lower face height. Ratings of nasolabial appearance showed more similarity between the centers.

CONCLUSION

The results confirm that systematic differences in craniofacial morphology and nasolabial appearance may occur between different cleft centers, but do not allow specific caused factors to be identified.

Three-dimensional quantification of the symmetry of normal facial movement

OBJECTIVE

This study examined the right to left symmetry of the displacement of three-dimensional movement of the human face.

METHODS

Displacement data on 42 subjects was collected and analyzed with the Expert Vision Motion Analysis System. Right and left three-dimensional facial displacements were quantified.

RESULTS

Significantly greater left than right three-dimensional displacement across the whole face was measured. The three-dimensional displacement difference ranged from 0.48 mm to 2.28 mm between the right and left sides of the face. The 2-cm inferior pupil markers during the nose wrinkle expression had significantly greater left than right displacement.

CONCLUSION

The ranges of displacement differences, along with the mean three-dimensional displacement measures, must be accounted for in the creation of a baseline of the range of normal facial movement.

Surgical results of primary lip repair using the triangular flap method for the treatment of complete unilateral cleft lip and palate: a three-dimensional study in infants to four-year-old children

OBJECTIVE

To evaluate morphological problems for children with complete unilateral cleft lip and palate (UCLP).

DESIGN AND SETTING

A cross-sectional study was performed on 46 patients with complete UCLP at Osaka University Dental Hospital.

PATIENTS AND PARTICIPANTS

The method was applied to three groups of children with UCLP (8 4-month-old infants, 18 1.5-year-old children, and 20 4-year-old children).

MAIN OUTCOME MEASURES

The three-dimensional coordinates of facial landmarks were extracted automatically from XYZ data sets and from photo images produced by an optical surface scanner.

RESULTS

The intercanthal distance, nose width, and mouth width were closer to those of normal children in the older group. Deviation of the columella toward the noncleft side was smaller in the 4-year-old group. The angle of the nasal tip was large in all groups. Asymmetry of the ala was conspicuous at the upper part of the nose in the vertical dimension. Asymmetry of the nostril was observed in the vertical dimension and in the anteroposterior dimension in the 4-year-old group. The angle of the Cupid's bow was obtuse on the noncleft side, and the bottom of the Cupid's bow deviated toward the cleft side. The Cupid's bow was longer on the noncleft side. Protrusion of the vermilion was poor in all groups.

Three-dimensional analysis of facial morphology in normal Japanese children as control data for cleft surgery

OBJECTIVE

This study presents an analysis of three-dimensional facial forms of normal Japanese children.

DESIGN AND SETTING

Cross-sectional data (n = 247) were available from the Ikeda Public Health Center.

PATIENTS AND PARTICIPANTS

Three groups of children (ninety-seven 4-month-old infants, fifty-four 1.5-year-old children, and eighty 3.5-year-old children) were analyzed using a three-dimensional anthropometric technique.

MAIN OUTCOME MEASURES

Three-dimensional coordinates of facial landmarks were extracted automatically from XYZ data sets and photo images of an optical surface scanner.

RESULTS

Only minor gender differences were noted. Lip height was not correlated with other facial dimensions. There was a significant correlation between upper face, nose, and mouth widths. Compared with adults, the upper face width was larger (approximately 70% to 80% of adults) than the middle and lower parts of the face. Width ratios were greater than height and depth ratios. The lip height ratio, however, was larger than the lip width ratio, and the angle of the cupid's bow was more acute in children. The angle of the nose was more obtuse, particularly in the axial plane.

CONCLUSIONS

In cleft lip surgery involving young children, there may be no need to consider gender differences. Some characteristic differences exist between children and adults, however, and normal standards for children would be helpful in plastic surgery.

A cephalometric inter-centre comparison of growth in children with cleft lip and palate

AIM

To examine whether the treatment provided by the Mount Vernon Cleft Team produces craniofacial growth outcomes comparable with that of the Oslo Team.

LOCATION

Mount Vernon Hospital, Middlesex, UK.

DESIGN

A retrospective cephalometric investigation.

SUBJECTS

Seventy-five Mount Vernon children and 150 Oslo children with complete unilateral or bilateral clefts of the lip and palate

METHOD

The subjects were matched for age, gender, and cleft type, and their radiographs were digitized. The radiographs from each site were grouped according to patient age (9-11 or 14-16) and cleft classification (bilateral/unilateral). Patients with associated craniofacial anomalies were excluded from the study.

RESULTS

Of the four variables studied (SNA, SNPg, NGn, sNANsPG) significant differences in maxillary growth were noted for bilateral and unilateral cleft groups at 14-16 years of age. The soft tissue profile was significantly flatter in bilateral and unilateral Mount Vernon cases at 14-16 years. The craniofacial growth exhibited by the Mount Vernon patients demonstrated 3.9-5.1 degrees reduction in maxillary prominence with respect to the Oslo sample. The bilateral cases from Mount Vernon had greater anterior face heights at 14-16 years.

CONCLUSION

The treatment provided by the Mount Vernon Cleft team leads to a reduced maxillary prominence in children aged 14-16 years compared with the Oslo sample. This reduction is statistically significant in unilateral cleft lip and palate.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 2: dentofacial outcomes and patient satisfaction

OBJECTIVE

To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom.

DESIGN

Cross-sectional outcome study.

SETTING

Fifty National Health Service cleft centers.

PARTICIPANTS

Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received.

MAIN OUTCOME MEASURES

Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction.

RESULTS

Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high.

CONCLUSION

A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.

Treatment outcome in cleft lip and palate: issues and perspectives

In the last 40 years, great progress has been made toward a better understanding of many aspects of the cleft lip and palate defect, but there is still a long way to go before there is agreement on the optimal treatment procedures. With regard to the primary operations, it can be stated, in a somewhat simplified form, that there are two main schools of thought in cleft treatment. One advocates early closure of the lip and palate, a procedure which imparts a high priority to early speech function. The other recommends delayed closure of the hard palate, thereby according a high priority to the growth of the maxilla. A number of intercenter and multicenter studies have been carried out recently in an effort to elucidate which procedures give the best result, both esthetically and functionally. The results are ambiguous, and this has led a number of researchers to suggest that the randomized clinical trial is the only way to resolve the ambiguity. The fact that it has proved difficult to identify the optimal procedures in the field of cleft lip and palate treatment need not only be due to a less than optimal research design; a contributory factor might also be the great variability in craniofacial morphology and in the response to treatment in patients who have exactly the same cleft lip and palate diagnosis. Intensive research has made it possible to state categorically that clefts occur due to many different factors in an interplay between genetics and environment. Therefore, it is not likely that a single gene can be responsible for clefting. Since scar tissue presents many problems-for instance, impairment of growth-the reduction or prevention of scar formation has long been a desirable goal. The discovery that a fetus can heal without scar formation has led to many animal experiments. The timing of the surgical intervention on fetuses is critical, since late-gestation fetuses heal with adult-like scarring. There are still many unsolved problems connected with fetal surgery, and at present prenatal surgery for repair of cleft lip and palate is not ethically defensible in humans. On the other hand, it appears that there are considerable possibilities for the reduction of human scarring after surgery with the introduction of various wound-healing medications.

A comparative study of prespeech vocalizations in two groups of toddlers with cleft palate and a noncleft group

OBJECTIVE

This study examined the prelinguistic contoid (consonant-like) inventories of 14 children with unilateral cleft lip and palate (C-UCLP) at 13 months of age. The children had received primary veloplasty at 7 months of age and closure of the hard palate was performed at 3-5 years. The results of this investigation were compared to results previously reported for 19 children with cleft palate and 19 noncleft children at the age of 13 months. The children with clefts in that study received a two-stage palatal surgery. This surgical procedure was formerly used at our center and included closure of the lip and hard palate at 3 months of age and soft palate closure at 22 months of age.

DESIGN

Retrospective study.

SETTING

The participants were videorecorded in their homes during play with their mothers. The videotapes were transcribed independently by three trained speech pathologists.

PATIENTS

Fourteen consecutive patients born with C-UCLP and no known mental retardation or associated syndromes served as subjects.

RESULTS

The children who received delayed closure of the hard palate demonstrated a significantly richer variety of contoids in their prespeech vocalizations than the cleft children in the comparison group. Both groups of subjects with clefts had significantly fewer plosives in their contoid inventory than the noncleft group, and there was no difference regarding place of articulation between the group that received delayed closure of the hard palate and the noncleft group.

Computer aided three-dimensional analysis of nostril forms: application in normal and operated cleft lip patients

The appearance of the nostril in cleft lip patients is very important in the subjective assessment of naso-labial forms and patient satisfaction. To improve the outcome of plastic surgery, a computer aided diagnostic system was developed. Facial forms were measured with a three-dimensional optical scanner (Ogis Range Finder RFX-IV) XYZ coordinates (256x240) and RGB (red, green, blue) image (512x480) data sets were then obtained with the apparatus. The nostril area was determined by discriminant analysis of the RGB data, and the landmarks of the nostril were extracted under geometric conditions. To assess the reliability of this technique with head inclination, five volunteers were measured in seven postures. Landmark stability was within approximately 1 mm when the Frankfort plane was 45-60 degrees. Subsequently, this system was applied to two cleft lip patients who had undergone a secondary nasal correction. For control data, 37 healthy adults (22 males and 15 females) were measured in the same manner. Nasal asymmetry in the unilateral case and wide and flat nostrils in the bilateral case were greatly improved after surgery. Conversely, the volume of the nasal tip decreased. This system was a great help in the diagnosis of nostril abnormalities.

Millard repair of unilateral isolated cleft lip: a 25-year follow-up

Twenty-five patients with isolated unilateral cleft lip took part in a follow-up study at a mean age of 28.6 years. All had had a primary, Millard lip repair, at a mean age of 4.6 months. In 20 patients, at least one secondary correction had been undertaken during adolescence. The overall long-term outcome was thought to be good, leaving a fairly inconspicuous fine lip scar and acceptable nose configuration. In half the patients, however, the lip was slightly elongated and the nostrils were still asymmetrical. These findings concurred with the patients' subjective assessments, which showed that appearance of the lip and nose were rated good by 20 (80%) and 16 (64%), respectively. The findings of this study provide a baseline for future evaluation of the results achieved with lip closure by Johanson's technique.

Facial growth after different methods of surgical intervention in patients with cleft lip and palate

Studies of the influence of surgery on facial growth in cleft lip and palate must take into account inherent variations in craniofacial form independent of surgery. Primary surgery, the most important iatrogenic influence on facial form, can differ in technique, timing, and sequence, and one of the major challenges in researching the topic is the remarkably varied clinical protocols in current use. Unfortunately, systematic attempts to compare dentofacial outcomes reported in the literature are unlikely to be reliable, as methodologic biases cannot be overcome. Rigorous intercenter studies can improve the dependability of data and provide evidence of the success of cleft services as a whole, but they are still subject to biases introduced by differences in surgical skills and underlying craniofacial form. These shortcomings are finally being overcome through multicenter randomized control trials.

Evaluation of the results of cleft lip and palate surgical treatment: preliminary report

OBJECTIVE

The aim of this study was to present a measuring tool, in the form of a dual-rating grid, for preoperative appearance and postoperative results in the treatment of labionasal clefts.

METHODS

This study was carried out on 43 children with partial unilateral clefts, operated on using a derivation of Millard's technique. The preoperative initial severity score (ISS) was the sum of points each corresponding to a precise anatomic anomaly. A severe cleft was given a rating of 6, and a mild cleft a rating of 1. The postoperative results score (PRS) was the sum of points corresponding to residual or acquired anatomic anomalies: a good result was given 0.5, and a poor result 3.5. Each score was a mark given separately and agreed on by two surgeons. To compare the rating grids, the correlation between the ISS and the PRS was calculated.

RESULTS

Twenty-four patients had an ISS less than 5; 19 patients had an IGS more than or equal to 5. Marks for the PRS were between 0.5 and 3.5 with the majority at 1 to 1.5.

CONCLUSION

This study demonstrates the coherent connection between these two pre- and postoperative rating grids.

Effect of primary surgery for cleft lip and palate on mid-facial growth

Surgery for cleft lip and palate is known to have an effect on growth and development of the mid-face. This paper studies the outcomes in 34 consecutive 10-year-old patients with unilateral cleft lip and palate. Clinical observations of the importance of both surgical technique and the influence of cranial base morphology on maxillo-mandibular position are discussed.

Facial growth in patients with unilateral clefts of the lip and palate: a two-center study

Two groups of 10-year-old patients with complete unilateral clefts of the lip and palate were examined in this study. Two centers; Bristol, U.K. and Oslo, Norway, who had different treatment regimens were used. The groups comprised 40 patients from Oslo and 32 from Bristol. The groups were matched, in proportion to the size of the groups, for age, sex, and presence of Simonart's bands. In Oslo, a Millard lip repaired was performed at 3 months of age with a von Langenbeck palatal repair at 18 months, no presurgical orthopedics was employed and there was no primary nasal correction. The Bristol center also repaired the lip at 3 months with a Millard type repair but also performed a radical nasal correction at the same time. The palate was repaired at 6 months with a Veau repair, and presurgical orthopedics using a pinned arch orthopedic plate was carried out. In addition, the volume of primary repairs per surgeon was much higher in Oslo, and a much stricter treatment protocol was used compared with Bristol. Lateral cephalograms obtained within 1 year of the child's tenth birthday were digitized, and the craniofacial morphology of the two groups was compared. Significant differences in maxillary growth and soft tissue profile were noted with a much more retruded mid-face and flatter nasiolabial angle in the Bristol group. The main factors for the better results in Oslo are suggested to be the absence of presurgical orthopedics, no radical nasal correction, the high volume of operations performed per surgeon, and the stricter protocol.