Mandibular growth in patients with cleft cleft palate the influence of cleft type
Omar Gabriel da Silva Filho," Antonio David Corr~a Normando, u and Leopoldlno Capelozza Filho c Bauru, Brazil
A total of 229 adult white patients with cleft lip or palate were evaluated, through cephalometric radiographs, to determine cleft-type influence on mandibular structure and spatial position. The sample includes adult patients with unilateral complete cleft lip and alveolus (n = 50), complete cleft lip and palate (n = 118), and isolated cleft palate (n = 61). A group of 65 subjects with normal occlusion and without cleft lip or palate was used as a control group. All groups were matched according to sex. When compared, the cleft groups and the normal group showed that the mandibular structure was significantly different. The mandible in the cleft groups displayed shorter mandibular ramus and body length, without difference between the cleft types. Mandibular position relative to cranial base was similar in the cleft groups with involvement of the palate, and differed significantly from that observed in the group with cleft lip and alveolus and in the subjects without cleft. Palatal clefts induce a significant downward and backward rotation of the mandible associated with a more obtuse gonial angle. Thus a small mandible is a structural characteristic of all cleft types studied. However, mandibular shape and spatial position are strongly influenced in clefts that involve the palate. (AMJ ORTHOO DENTOFACORTHOP 1993;104:269"75.)
C e p h a l o m e t r i c studies have shown that there are well-known differences concerning facial relationships in cleft and noncleft populations. These differences can be attributed to: (I) the management of the lip and/or palate, (2) functional changes resulting from the mechanical presence of the cleft, (3) genetic pattern, or (4) a combination of these factors. The literature reports that surgical influences differ for each cleft type and for the different facial bones. Regarding the midface growth in the isolated cleft lip, cheiloplasty is associated with more favorable profiles, 2"3 whereas deleterious effects are pointed out in the clefts involving lip and palate, because of the greater extension of the affected structures2 s In the isolated cleft palate, palatoplasty does not interfere in anteroposterior maxillary growth. When comparing subjects with cleft with those without cleft, the differences regarding this dimension can only be attributed to the presence of the cleft. 3"9"1~ Despite the beneficial and deleterious effects that surgical procedures produce in maxillary growth, the From the Hospital de Pesquisa e Reabilita~5o de Lesres 12tbio-Palatais(HPRLLP), University of Silo Paulo, Bauru. Brazil. This research was supported by CAPES (Coordena~r,o 9 Apeffei~oamento de Pessoal de Nfvel Superior). "Orthodontist. ~rthodontie Resident. 9Head Orthodontic Sector. Copyright 9 1993 by the American Association of Orthodontists. 0889-5406193151.00 + 0.10 8/1/34706
mandible is apparently not influenced by surgical management.2-t t The influence of the cleft itself on the mandibular growth has not been adequately discussed. Previous studies have shown that there are differences between cleft types. Regarding mandibular spatial position, the literature shows a downward and backward mandibular rotation in subjects with cleft lip and palate when compared with patients with cleft lip, ~.~.12whereas no differences were observed between children 13 or adults s with isolated cleft palate and cleft lip and palate. Dahl et al. ~4 reported an increased backward inclination of the mandible in relation to cranial base in newborns with isolated cleft palate when compared with newborns with cleft lip, although no difference was observed when the gonial angle was evaluated. The findings concerning mandibular dimensions are conflicting. Krogman et al. '3 did not find significant differences between subjects with cleft lip and palate and subjects with isolated cleft palate, and DahP found a smaller mandibular ramus in men with cleft palate compared with men with cleft lip. However, Dahl et al. ~*found smaller mandibles in newborns with isolated cleft palate compared with newborns with cleft lip, whereas Bishara et al. ~ observed a larger mandibular length in cleft lip and palate compared with cleft lip. The few articles available that compared the different cleft types adding to the conflicting findings reported in the literature have encouraged us to evaluate 269
AmericanJournalof Orthodonticsand DentofaciatOrthopedics September 1993
da Sih'a, Normando, and Capelozza
Fig. 1. Occlusal view of types studied: A, Complete unilateral cleft lip and alveolus. B, Complete unilateral cleft lip and palate. C, Complete bilateral cleft lip and palate. D, Isolated cleft palate.
Table I. Percentual distribution of the sample according to sex for each group and mean age Groups
Sex Male Age (~) Female Age (~) TOTAL(n)
Unilateral cleft lip and ah,eolus
Complete cleft lip and palate, unilateral (n = 78) and bilateral (n = 40)
Number I Percentage
Number I Percentage
Number I Percentage
35 18y 30 18y
(54%) 9m (46%) 5m 65
28 19y 22 19y
(56%) 9m (44%) i lm 50
mandibular structure and spatial position in different cleft types compared to subjects without cleft by using a large sample o f subjects with cleft.
MATERIAL AND METHODS Material The sample consists of lateral cephalometric radiographs of 229 patients of the Hospital de Pesquisa e Reabilita~5,o de Les6es L,"ibio-Palatais (IIPRLLP) of the University of Silo Paulo (USP), Brazil, displaying cleft lip and/or cleft palate, with no other associated malformation (Table I). All patients were white, with permanent dentition, and had not been subjected to previous orthodontic treatment. The youngest patient in the male group was 15 years old, and the youngest in the female group was 14 years old (mean age was 19 years and 4 months for males and 19 years and 3 months for females).
66 19y 52 18y
(56%) 5m (44%) 9m 118
Cleyt Isolated cleft palate
Number I Percentage
31 19y 30 19y
(51%) l lm (49%) 2m 61
125 104 229
The results of a previous article by Silva Filho et al." revealed great similarity in the structure and spatial position of the mandible, within the same type of cleft, among persons who had cleft lip or palate and had undergone surgery or had not undergone surgery. The'surgical factor was disregarded because of this morphologic similarity, and the sample was divided according to cleft type only. Three main cleft groups were considered (Table 1): unilateral cleft lip and alveolus (n = 50); cleft lip and palate (n = 118); and isolated cleft palate (n = 61) (Fig. 1). The cleft lip and palate group consisted of 78 subjects with unilateral clefts and 40 subjects with bilateral clefts. The mean age when the cephalometric radi6graphs were taken is shown in Table 1. The control group consisted of 65 white adults with "normal occlusions" (35 men and 30 women with permanent den-
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Volume 104, No. 3
Fig. 2. Anatomic tracing with cephalometric points, linear and angular measurements used: (1) S-N; (2) S-Go; (3) N-Me; (4) Go-Gn; (5) Co-Gn; (6) Co-Go; (7) P-NB; (8) SNB; (9) SN-Go-Gn; (10) SN-Gn; (11) Co-Go-Me.
tition) with a mean age of 18 years and 9 months for the male group and 18 years for the female group. All three cleft groups and the control group were matched according to sex (Table I). One-way analysis of variance was used to observe the differences between group means; comparison among the three main cleft groups and between these groups and the control group were undertb.ken with Tukey's test. Methods On lateral cephalograms and using points S (sella), N (nasion), Gn (gnathion), Go (gonion), Me (menton point), ANS (anterior nasal spine), P (pogonion), B (supramental), and Co (condilion), the structure of the mandible (Go-Gn, Co-Go, Co-Gn, P-NB, CoGoMe) and its spatial position in relation to the anterior cranial base (S-Go, N-Me, SNB, SnGo-Gn) and maxilla (ANS-Me) were appraised (Fig. 2). RESULTS AND DISCUSSION Craniofacial structure, determined initially by genetic inheritance, is strongly influenced during growth b y extrinsic or environmental factors. In patients with cleft lip or palate the anatomic reconstruction of the lesions by surgical procedures plays an important role in the final facial aspect. Nevertheless, in a recent article, Silva Filho et al." reported that the structure and spatial position of the mandible are not influenced by surgical procedures. So it can be assumed that if there are any differences in the mandibular pattern between persons with and persons without cleft lip or cleft pal-
ate, these differences cannot be attributed to the surgical management. Therefore the aim of this article is to study the characteristic structure of the mandible in the different cleft types and to compare them with normal persons displaying normal occlusions. The analysis of Tables II and III showed that the mandibular structure is altered in all cleft types studied. These results can be easily evaluated by analyzing the cephalograms in Figs. 3, 4, and 5, which show striking differences between the cleft group and the normal group studied. In the cleft group, the mandibular dimensions at the level of the ramus (S-Go, Co-Go), body (Go-Gn), and the total length (Co-Gn) are smaller in all cleft types without any differences between them. According to these data, it can be thought that the, cleft itself leads to alterations in mandibular dimensions irrespective of the cleft type. Thus the findings of the present article do not support the hypothesis that there is a relationship between mandibular size and cleft of the palate.~5.16 Therefore the present data are in agreement with findings of Krogman et al. ~3 and Bishara et al. ~2 and do not agree with the findings of Dahl etal. 14 and Bishara et al., I which reported significant differences in mandibular dimensions among cleft types. We think that the differences observed by Dahl et al. 14 and Bishara et al. 1 can be a result of nonmatching samples according to gender in the studies of those authors. Besides the proportional reduction in mandibular
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American Journal of Orthodontics and Dentofacial Orthopedics September 1993
Fig. 3. Superimposition on SN, with mean values for mandibular position and morphology between normal ( - - - - ) and unilateral cleft lip and alveolus ( . . . . ) groups.
Table II. Means and standard deviation for the groups examined Noncleft (n = 65)
Cleft lip and ah'eolus (n = 50)
Cleft lip and palate (n = 118)
Isolated cleft palate (n = 61)
Anterior cranial base
82.34 63.72 127.99 2.18 124.56
(4.97) (4.70) (6.73) (1.43) (5.03)
76.67 58.14 119.64 2.43 127.09
(5.49) (5.70) (7.83) (1.92) (6.68)
76.91 56.28 120.80 3.25 132.34
(6.28) (5.90) (8.48) (2.18) (7.04)
77.01 56.17 121.22 2.72 132.92
(5.91) (6.01) (8.33) (2.37) (5.61)
(6.72) (10.09) (8.16) (3.28) (6.09) (4.29)
77.60 125.88 79.94 77.67 36.62 68.92
(7.78) (11..12) (9.30) (4.75) (8.30) (5.66)
77.28 126.79 73.75 78.38 37.95 69.32
(7.27) (8.29) (6.36) (3.52) (5.95) (3.69)
Go-Gn Co-Go Co-Gn P-NB CoGoMe
Spatial mandibular relationship to cranial base and to maxilla
S-Go N-Me ANS-Me SNB SNGoGn SNGn
83.84 126.81 71.91 80.18 29.73 66.01
(6.13) (6.83) (5.42) (3.21) (4.03) (2.95)
79.73 121.85 71.69 79.46 31.64 67.02
dimensions, the comparison between the cleft lip and alveolus group w i t h the noncleft group (Table III and Fig. 3) shows that, except the lower anterior facial height, all other facial heights (S-Go, N-Me) are shorter
in the cleft group. Anteroposteriorly, the SNB angles are similar to the group without cleft, because the shorter mandibular length (Co-Gn, Go-Gn) is balanced by the proportionally shorter anterior cranial base length 9
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Fig. 4. Superimposition on SN with mean values for mandibular position and morphology between normal ( - - - - ) and complete cleft lip and palate ( . . . . ) groups.
Table IlL D i f f e r e n c e s b e t w e e n g r o u p m e a n s a n d statistical analysis b y test o f T u k e y - K r a m e r Noncleft • cleft lip and ah'eolus S-N Go-Gn Co-Go Co-Gn P-NB CoGoMe S-Go N-Me ANS-Me SNB SNGoGn SN-Gn
4.11 * 5.67* 5.58* 8.35* -0.25 - 2.53 4. I 1" 4.96" 0.22 0.72 - 1.91 - 1.01
Nonc/eft • cleft lip and palate 3.55" 6.43* 7.44* 7.19" - 1.07" - 7.78* 6.24* 0.93 - 3.03 2.51" -6.89* -2.91"
Nondeft x isolated cleft palate 4.52* 5.33* 7.55* 6.67* -0.54 - 8.36* 6.56* 0.02 - 1.84 1.80 -8.22* -3.31"
Cleft lip and ah.eohts • cleft lip and palate - 0.56 - 0.24 1.86 - 1.16 -0.82 - 5.25* 2. ! 3 - 4.03 - 3.25 1.79" -4.98* - 1.90
Cleft lip and alveolus • isolated cleft palate 0.41 - 0.34 1.97 - 1.58 -0.29 - 5.83* 2.45 - 4.94* - 2.05 1.08 -6.30* -2.30*
Cleft lip and palate • isolated cleft palate 0.97 - 0. I0 0.11 -0.42 0.53 - 0.58 0.32 - 0.91 I. 19 - 0.71 - 1.33 -0.40
*P < 0.05.
(S-N), denoting growth equivalents between mandible and a n t e r i o r cranial b a s e in s u b j e c t s w i t h cleft lip and alveolus. A l t h o u g h t h e r e is a similarity in m a n d i b u l a r s h a p e and spatial p o s i t i o n b e t w e e n the g r o u p w i t h o u t cleft and the g r o u p w i t h cleft lip a n d a l v e o l u s the s a m e c a n n o t
b e o b s e r v e d for t h e g r o u p s w i t h cleft lip and palate and i s o l a t e d cleft palate. ( S e e F i g s . 4 a n d 5). In the c l e f t groups besides vertical b y the
that i n v o l v e the palate the m a n d i b l e s h o w e d , the s h o r t e r r a m u s and b o d y l e n g t h s , a m o r e g r o w t h p a t t e r n . T h i s finding can b e c o n f i r m e d d e c r e a s e d p o s t e r i o r facial h e i g h t ( S - G o ) , a
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American Journal of Orthodontics and Dentofacial Orthopedics September 1993
i - \"X. ~
".~ ~176176176176176176176176176176 -~
". 9 9
..i Fig. 5. Superimposition on SN, with mean values for mandibular position and morphology between normal ( - - - - ) and isolated cleft palate ( . . . . ) groups.
greater anterior facial height (N-Me), a more obtuse gonial angle (CoGoMe), and a downward and backward rotation of the mandible relative to cranial base (SNGoGn). Concerning the anteroposterior spatial relationship of the mandible to the cranial base (SNB) the clefts that involved the palate show a mandibular retroposition in relation to subjects without cleft. This fact is due to a greater downward and backward rotation of the mandible, leading to a more posterior position of the landmark B. Mandibular and anterior cranial base lengths are similar to those found in the 9 lip and alveolus group, where mandibular position was not significantly different from normal group. Despite morphologic differences that distinguish the pattern of cleft groups from the noncleft group, the mandibular structure and spatial position are not similar for the different types of cleft evaluated. The superimposition of cephalograms in Fig. 6 clearly shows that there are differences among the types of cleft studied. A comparison between cleft lip and palate and isolated cleft of palate did not reveal significant differences among these groups with involvement of palate (Table III), though both groups differ significantly from the cleft lip and alveolus group. This similarity between
subjects with isolated cleft palate and subjects with cleft lip and palate corroborates the limited data in the literature.5.12.~s Thus palatal involvement in the cleft is associated with a mandibular downward and backward rotation, denoted by an increase in the gonial angle and consequently leading to an increase of total anterior facial height. The question must still be answered as to whether changes are determined by genetic inheritance or by other environmental factors. CONCLUSIONS
The structure and spatial position of the mandible in patients with cleft lip or palate show significant differences when compared with the noncleft group. The results indicate that clefts, irrespective of the type, have smaller mandibles than in the normal group when examined in adulthood. Mandibular pattern in clefts that involve the palate differ significantly from that found in subjects with cleft lip and alveolus and normal subjects. Clefts involving the palate are associated with more vertical growth of the face, associated with changes on mandibular shape (gonial angle) and consequently a backward rotation of the mandible.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 104, No. 3
da Sih'a, Normando, and Capelozza
Fig. 6. Superimposition on SN with mean values for mandibular position and morphology among different types of clefts studied: unilateral cleft lip and alveolus ( . . . . ); complete cleft lip and palate ( . . . . ); isolated cleft palate ( - - - - ) .
We thank Dr. Luis Torelly and Dr. Antonio Assun~ao for their assistance in the English version.
REFERENCES I. Bishara SE, Krause CJ, Olin WH, et al. Facial and dental relationships of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J 1976;13:238-52. 2. Silva Filho OG, Rocha R, Capelozza Filho L. Padrfio facial do paciente portador de fissura pr,~-forame incisivo unilateral completa. Rev Bras Cirurg 1989;79:197-205. 3. Nor'mando ADC, Silva Filho OG da, Capeloz.za Filho L. Influence of surgery on maxillary growth in cleft lip and/or palate patients. J Craniomaxillofac Surg 1992;20:i 1I-8. 4. Hagerty RF, Hill MF. Facial growth and dentition in the unopcrated cleft palate. J Dent Res 1963;42:412-21. 5. Dahl E. Craniofacial morphology in congenital clefts of the lip and palate: an x-ray cephalometric study of young adult males. Acta Odont Scand 1970;28(Suppl 57):1-166. 6. Ross RB. Treatment variables affecting facial growth in cleft lip 9 and palate: 6. Techniques of palate repair. Cleft Palate J 1987;24:64-70. 7. Mars M, Houston WJB. A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J 1990;27:7-10. 8. Silva Filho 0(3, Lauds RCM, Cavassan AO. Pacientes tissurados de l;tbio e palato: efeitos suscitados pela queiloplastia. Ortodontia 1990;23:25-34. 9. Bishara SE. Cephalometric evaluation of facial growth in op-
crated and nonoperated individuals with isolated clefts of the palate. Cleft Palate J 1973;10:239-46. Silva Filho OG, Cavassan AO, Normando ADC. lnflu~ncia da palatoplastia no padrfio facial de pacientes portadores de fissura prs-forame incisivo. Rev Bras Cirurg 1989;79:315-22. Silva Filho OG da, Normando ADC, Capelozza Filho L. Mandibular morphology and spatial position in cleft lip and/or palate patients: intrinsic pattern on influenced by surgical procedures? Cleft Palate J 1991 [in press]. Bishara SE, De Arredondo RS, Vales tiP, et al. Dentofacial relationships in persons with unoperated clefts: comparisons between three cleft types. A.,,I J OR'nton 1985;87:481-507. Krogman WM, Jain RB, Oka SW. Craniofacial growth in different cleft types from one month to ten years. Cleft Palate J 1982;19:206-11. DalaiE, Krciborg S, Jensen BL, et al. Comparison of craniofacial morphology in infants with incomplete cleft lip and infants with isolated cleft palate. Cleft Palate J 1982;19:258-66. Jelinek R, Peterka M. The role of the mandible in mouse palatal developmental revisited. Cleft Palate J 1977;14:211-21. Smahel Z. Craniofacial changes associated with cleft palate: the role of mandible in development of clefts. Nova Acta Leopoldina 1986;58:217-21.
Reprint requests to: Dr. Omar Gabriel da Silva Filho Rua Silvio Marchione, 3-20 Caixa Postal, 620 17043-Baum-SP Brazil