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Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Evaluation of the Facial Soft-Tissue Thickness in Patients
With Cleft Lip and Palate
Emire Aybuke Erdur, PhD,
Zeliha Muge Baka, PhD,
yMerve Fidanboy, PhD,
yand Omer Erdur, MD
zAim: In this study the authors aimed to evaluate craniofacial morphology and facial soft tissue thickness of the patients with cleft lip and palate.(CLP), and to compare the results with a sex and age-matched noncleft healthy control group.
Methods: Craniofacial and soft tissue thickness measurements of 20 patients with unilateral cleft lip palate (UCLP) and 20 patients with bilateral cleft lip palate (BCLP) were compared with 20 noncleft control subjects. Angles between Nasion-A point, Sella-Nasion-B point, Nasion-A and Sella-Nasion-B line, Sella-Nasion line and Gonion-Gnation line, and linear (glabella, rhinion, subnasale, labrale superius, stomion, labrale inferius, labiomentale, pogonion, and gnathion) measurements were assessed on lateral cephalometric radiographs. Group differences were evaluated with 1-way analysis of variance and post hoc Tukey test.
Results: Unilateral cleft lip palate and BCLP groups demonstrated lower values of skeletal measurements than control group except for Sella-Nasion line and Gonion-Gnation line value (P < 0.01). Maxillary incisors were retruded in BCLP group compared with the other groups (P < 0.001). Thickness of the rhinion, subnasale, and stomion demonstrated no significant difference between UCLP and BCLP groups (P > 0.05). Thickness of rhinion and stomion was found significantly higher in both groups, and thickness of the subnasale was found significantly lower than the healthy group (P < 0.05). Conclusion: Findings of the study suggested that patients with CLP showed differences on craniofacial morphology and facial soft tissue thickness. Before planning orthodontic treatment and esthetic surgeries, soft tissue thickness should be taken into consideration in addition to skeletal measurements in CLP patients.
Key Words:Cleft lip and palate, facial morphology, soft tissue, thickness
(J Craniofac Surg 2019;30: 1706–1709)
C
left lip and palate (CLP) is a common congenital craniofacial developmental disorder and it is an adhesion deficiency of the primary palate.1 – 4Patients with CLP generally have feeding problems, speech pathologies with dental, and skeletal anomalies in addition to socio-psychological problems.5 Because of various craniofacial problems a multidisciplinary team including pedodontics, orthodontics, maxillofacial surgery, audiology, otorhi-nolaryngology, prosthodontics must be included for the therapeutic follow-up of these patients.After the surgical correction of CLP, these patients have reduced maxillo-mandibular development and extended vertical dimen-sions.6,7The most important factor for the formation of maxillary deficiency seems scarring which was occurred after the primary surgical correction.8Generally, Class III malocclusion with anterior and posterior crossbites was observed in these patients.9 – 11The favorable facial morphology and esthetics is one of the main aim of these patients’ treatment strategy.12It is well known that hard tissue and related soft tissue have a close relationship between each other. The assessment of soft tissue is essential for the patients requiring orthodontic treatment and orthognathic surgery. Thus, evaluation of soft tissue in CLP patients seems crucial for the favorable facial morphology.
Cephalometric lateral film is a routine and effective assessment tool of the orthodontic treatment plannings.13 There are some studies evaluating the soft-tissue of the CLP patients with different methods.7,13– 18Most of these studies were about unilateral cleft lip
palate (UCLP) as a consequence of low frequency of bilateral cleft lip palate (BCLP). These studies have reported facial soft-tissue differences compared with healthy controls and pointed this eva-luation’s importance in both diagnosis and treatment of CLP patients. However, there were few studies evaluating both UCLP, BCLP patients and comparing them with matched controls and a consensus on this issue has not been formed.6,7,10,16In this retro-spective cross-sectional study we aimed to compare the soft tissue thickness of the UCLP, BCLP patients, and a healthy controls. In addition, the correlation of skeletal growth patterns with the soft tissue thickness was evaluated.
METHODS
This retrospective study was approved by the local ethics committee. The lateral cephalometric radiographic data used in the present study were collected due to their cleft presence and dental treatment needs. None of the cephalometric graphs were taken for this study; all were necessary for clinical diagnosis or orthodontic treatment. The patients and parents had signed an informed consent form allowing the researchers to use their data for scientific aims. All of the study patients were operated with the same surgical protocol at same hospital. Factors that may affect the facial soft-tissue of both study and control groups like maxillofacial neoplasia, trauma, infection or surgery, orthodontic and prosthodontic treatment, and any diagnosed craniofacial syndrome were excluded from the study.
Sample size estimation was based on a similar study by Celi-koglu et al19 who evaluated soft tissue of UCLP patients and compared with a control group. Using the findings of this previous
From theDepartment of Orthodontics, Faculty of Dentistry, Necmettin
Erbakan University; yDepartment of Orthodontics, Faculty of Dentistry; and zDepartment of Otorhinolarygology, Medical Faculty, Selcuk Uni-versity, Konya, Turkey.
Received October 24, 2018.
Accepted for publication February 24, 2019.
Address correspondence and reprint requests to Emire Aybuke Erdur, PhD, Emire Aybuke Erdur Department of Orthodontics, Faculty of Dentistry, Necmettin Erbakan University, 42050 Konya, Turkey;
E-mail: dtaybuke@gmail.com The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofa-cialsurgery.com).
Copyright#2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005504
O
RIGINALA
RTICLECopyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
study, with an a error of 0.05 and a power of 85%, 17 patients were required for each group according to the power analysis. Twenty patients were included to increase the power of the study.
Patients (ages 10–16 years) were retrospectively selected for 3 groups as UCLP, BCLP, and control groups. The UCLP group included 20 patients (10 women, 10 men; mean age: 14.05 2.68 years). The BCLP group included 20 patients (10 women, 10 men; mean age: 14.67 4.28 years). The control group included age- and sex-matched 20 healthy patients (10 women, 10 men; mean age: 14.05 2.68 years) without any cleft. These healthy patients were selected from the archives of Orthodontics Clinic who had dental examination with no craniofacial anomaly.
Cephalometric Analysis
For each subject lateral cephalometric radiographs were taken under standard conditions with the head orientated along the Frankfort horizontal plane. All cases were placed their teeth in centric occlusion and relaxed their lips in resting position. For all subjects Planmeca (Promax, Dimax 3 Ceph, Helsinki, Finland) cephalometry x-ray machine was used for cephalometric graphs. All digital radiographs were analyzed on the same computer (Figs. 1 and 2).
The same experienced orthodontist (EAE) analyzed all mea-surements, for preventing inter observer variability. All data were measured in millimeters and all digital radiographs were corrected for magnification.
Statistical Analysis
To assess the method error level of measurements, 20 cephalo-grams were randomly selected, and measurements were repeated at a 2-week interval by the same orthodontist (EAE). The Dahlberg formula was used to calculate method error, and systematic error
was calculated by paired-samples t tests at P < 0.05. The differences between the first and second measurements were not significant.
All statistical analyses were performed with the statistical package for social sciences, 21.0 (SPSS for Windows; SPSS Inc, Chicago, IL) at P < 0.05. Normality and homogeneity of the data was tested and all data was normally distributed with homogeneous variance. Therefore parametric tests were used to evaluate the data. In each group, mean and SD of all measured parameters were calculated using descriptive statistics. Group differences were evaluated with ANOVA and post hoc comparisons were done using the Tukey test. Multiple linear regression analyses were used to define the relationship between the craniofacial and the soft-tissue thickness measurements.
RESULTS
Supplemental Digital Content, Table 1, http://links.lww.com/SCS/ A915 presents the patients’ skeletal measurements in all groups. Unilateral cleft lip palate and BCLP groups showed lower values of skeletal measurements than control group except for Sella-Nasion line and Gonion-Gnation (SN-GoGn) value. Sella-Nasion-A point (SNA), U1-SN, and IMPA angle demonstrated significantly statis-tical differences between the groups (P < 0.01). Unilateral cleft lip palate and BCLP groups had decreased SNA and IMPA angle than the control group (P < 0.01). Bilateral cleft lip palate group had retruded maxillary incisors compared with the other groups (P < 0.001).
Supplemental Digital Content, Table 2, http://links.lww.com/ SCS/A915 presents the soft tissue thickness measurements of patients in all groups. Thickness of the rhinion, subnasale, and stomion demonstrated significant differences between the groups (P < 0.01). While thickness of the rhinion, subnasale, and stomion demonstrated no significant differences between UCLP and BCLP groups, in both groups, thicknesses of rhinion and stomion were found to be significantly higher and thickness of the subnasale was found to be significantly lower than the matched controls.
Supplemental Digital Content, Table 3, http://links.lww.com/ SCS/A915 presents the results of multiple linear regression analysis that was performed to define the statistically significant differences of rhinion, subnasale, and stomion as dependent variables and the
FIGURE 1. Facial soft tissue thickness measurements used in the study: Glabella (G), Nasion (N), Rhinion (Rhi), Subnasale (Sn), Labrale superius (Ls), Stomion (Sto), Labrale inferius (Li), Labiomentale (Labm), Pogonion (Pog), and Gnathion (Gn). Points G, N, Rhi, Pog, and Gn were perpendicular to Frankfort horizontal plane or to the bony surface. The remaining points were measured as follows: point; Sn, the distance between point A and subnasale; Ls, the distance between prosthion and labrale superious; Sto, the shortest distance between the upper incisor and the attachment points of the upper and lower lip; Li, the distance between infradentale and the vermilion border of the lower lip; Labm, the distance between point B and the deepest point of the labiomental crease.
FIGURE 2. Craniofacial measurements used in the study: SNA, SNB, ANB, SN-GoGn, Co-A (mm), CoGn (mm), U1-SN, and IMPA. SNA, Sella-Nasion-A point; SNB, Nasion-B point; ANB, Nasion-A and Nasion-B line; SN-GoGn, Sella-Nasion line and Gonion-Gnation line.
The Journal of Craniofacial Surgery Volume 30, Number 6, September 2019 Soft Tissue in Cleft Lip Palate
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
skeletal measurements as predictors. According to this analysis, statistically significant relationships were found for subnasale (R2¼ 0.887, P ¼ 0.000) and stomion (R2¼ 0.933, P ¼ 0.000) using
SNA, Sella-Nasion-B point (SNB), ANB, SN-GoGn, Co-A, Co-Gn, U1-SN, and IMPA in BCLP group (P < 0.05). SN-GoGn (r¼ 0.423, P ¼ 0.031), U1-SN (r ¼ 0.740, P ¼ 0.000), and IMPA (r¼ 0.605, P ¼ 0.002) were the best predictors for the subnasale while SNB (r¼ 0.741, P ¼ 0.000), ANB (r ¼ 0.802, P ¼ 0.000), SN-GoGn (r¼ 0.685, P ¼ 0.000), Co-A (r ¼ 0.403, P ¼ 0.039), and IMPA (r¼ 0.535, P ¼ 0.008) were for stomion.
DISCUSSION
Recently patients’ soft-tissue morphology has made interest for clinicians. The main reason for this interest was the need of the soft-tissue assessment for the patients undergoing orthodontic treatment and orthognathic surgery to obtain the best aesthetics results. While planning the orthodontic treatment and orthognathic surgeries, the soft tissue evaluation is crucial for obtaining the favorable facial esthetics besides the craniofacial assesments.14,19The scar tissues resulted after their surgical trauma and postoperative skeletal deformities may cause morphologic soft tissue changes for all of the CLP patients. And as a consequence the evaluation of the soft tissue of CLP patients is much more important for their dental and skeletal treatment strategy.
Previously, the soft tissue assessments of the CLP patients were evaluated; however, these studies were lack of elucidation about repair surgery and their scar effect on soft tissue.1,20–22More recently, the studies standardized the CLP patients and evaluated the patients who were operated in early childhood. But soft tissue differences of CLP patients are still less understood because of the limited number of studies on this field. Most of these studies were evaluating the patients with UCLP and very few studies were evaluating the BCLP patients. In this study, we evaluated both UCLP, BCLP patients and their surgical treatment protocols were the same.
Hasanzadeh et al23evaluated the soft tissue of adolescent patients with BCLP and found retruded and thinner nasal base, and reduced upper lip length with a flatter facial profile. Their study revealed thicker labrale inferior and thinner subnasale in females, and thinner subnasale in males. Celikoglu et al16 evaluated the soft tissue of patients with BCLP for pediatric age and found thinner subnasale, and labrale superior. They also compared the soft tissue of the males and females, and found no difference between the groups. In this study, we found thinner subnasale and thicker rhinion and stomion in BCLP group compared with noncleft patients. Liu et al15evaluated the soft tissue of the patients with UCLP and found thinner subnasale, shorter upper lip, reduced upper lip projection and increased lower lip projection, thicker upper and lower lips, flatter nasal tip, retrognathic nasal base with concave profile. In another study Celikoglu et al19
evaluated the soft tissue thickness of the patients with UCLP and they found significantly thinner subnasale and labrale superius. Similar to these studies, in our study UCLP group had thinner subnasale thickness than the control group. On the other hand, the findings were similar in both UCLP and BCLP groups.
Although cephalometric radiographs have some limitations it is the gold standard method for the orthodontic diagnosis and treat-ment protocols and became a routine film that is being used for all cases. Cone beam computed tomography (CBCT) is a commonly used imaging technique for dental and craniofacial treatment planning for over years, but CBCT has some disadvantages such as they have higher radiation dose, more expensive and their imaging is poor soft tissue contrast and artifacts compared with the conventional imaging techniques.24 – 26 Shaw et al26 found similar results with 2-dimensional lateral skull images of cephalo-metric radiographs and 3-dimensional CBCT images. The soft
tissue evaluations of all CLP patients with cephalometric radio-graphs give valuable findings and we think all patients’ both craniofacial and soft tissue assessment must be done for preventing unfavorable results.
In this study, we found rhinion, subnasale, and stomion signifi-cantly different to control patients. The thickness of the rhinion, subnasale, and stomion demonstrated no significant difference between the CLP groups. Thicknesses of rhinion and stomion were found to be significantly higher and thickness of the subnasale was found to be significantly lower than the control group. The multiple linear regression analysis was made to find the effects of craniofa-cial morphologic values. Statistically significant relationships were found for subnasale (R2¼ 0,887, P ¼ 0.000) and stomion
(R2¼ 0.933, P ¼ 0.000). The SN-GoGn and U1-SN showed the highest correlation for the thickness of subnasale and SNB, SN-GoGn, Co-A for the thickness of stomion.
The differences between our findings and those of other studies might be mainly due to the use of different radiograph techni-ques.15,16,19,23Another factor might be the distribution of the sexes, sample sizes, ages, and the treatment protocol of patients. In this study groups were approved to be very similar, the sample calculation method was performed to obtain the best possible measurements.
Before planning orthodontic treatment and orthognathic surgery of CLP patients, soft tissue thickness should be taken into consid-eration in addition to skeletal measurements for the best treatment choice. The present study provides information that would help the clinicians for the treatment planning of the patients with CLP. Further clinical trials with larger size of samples are needed for standardization of these soft tissue measurements.
CONCLUSION
Both the BCLP and UCLP patients showed thinner subnasale and thicker rhinion and stomion. The differences of the soft tissue thickness must also be considered for the treatment planning of CLP patients.
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