Morphologic and Management Characteristics of Individuals With Unilateral Cleft Lip and Palate Who Required Maxillary Advancement

Snehlata Oberoi, D.D.S., M.D.S, Radhika Chigurupati, B.D.S., D.M.D, Karin Vargervik, D.D.S
Objective: To delineate factors that may contribute to maxillary hypoplasia requiring maxillary advancement surgery in individuals with nonsyndromic unilateral cleft lip and palate (UCLP). Methods: This retrospective, longitudinal study used lateral cephalometric radiographs and chart reviews of 16 nonsyndromic UCLP individuals who underwent Le Fort I maxillary advancement and 16 controls matched for cleft type, age, and gender. Cephalometric measurements were made at three time points (T1, T2, and T3): mean ages of 10.7, 13.3, and 15.8 years for the Le Fort group and 10.11, 12.9, and 15.7 years, respectively, for the control group. Information regarding team care, timing and number of surgical procedures, and number of congenitally missing teeth were determined from clinical records. Results: The Le Fort group had significant maxillary hypoplasia at all time points compared to the UCLP controls, indicated by midface length measurements, ANB and Wits analysis (p < .001). The Le Fort group had twice the number of palatal surgical procedures and number of missing teeth in the maxillary arch as compared with the cleft controls. Most of the control group had consistent team care, while most of the surgical group did not. Conclusions: Maxillary hypoplasia that will require a Le Fort I advancement can be determined as early as age 10. Multiple missing maxillary teeth, secondary palate procedures including pharyngeal flaps, and inconsistent team care with delayed orthodontic intervention are contributing factors to maxillary underdevelopment. KEY WORDS: Le Fort I osteotomy, maxillary hypoplasia, unilateral cleft lip and palate

Cleft lip and/or cleft palate constitutes the most common congenital malformation of the head and neck, with a prevalence of 10.48 affected infants per 10,000 live births for cleft lip with or without cleft palate and 6.39 for cleft palate alone, accounting for approximately 6800 cases annually in the United States (Canfield et al., 2006). Although the treatment of children with cleft lip/palate has improved over the years, deficient growth of the maxilla is still common. The typical appearance of a cleft individual

Dr. Oberoi is Assistant Clinical Professor, Center for Craniofacial Anomalies, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, California. Dr. Chigurupati is Associate Clinical Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, University of California, San Francisco, California. Dr. Vargervik is Larry L. Hillblom Professor in Craniofacial Anomalies, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, California. Presented at the ACPA 62nd Annual Meeting, April 7, 2005, Myrtle Beach, South Carolina. Submitted March 2006; Accepted July 2007. Address correspondence to: Dr. Snehlata Oberoi, University of California, San Francisco, 513 Parnassus Avenue, S-747, San Francisco, CA 94143-0442. E-mail sneha.oberoi@ucsf.edu. DOI: 10.1597/06-053.1 42

with maxillary hypoplasia is a concave facial profile, lack of adequate upper lip support and nasal tip projection, decreased upper incisor display, and anterior and posterior crossbites. Maxillary deficiency is evident in the anterior-posterior (AP), vertical, and transverse dimensions. Many authors have studied characteristics of maxillary growth in unilateral cleft lip and palate (UCLP) at various ages. The AP dimensions in children younger than 8 years have been described as being either predominantly normal (Vargervik, 1981; Han et al., 1995; Casal et al., 1997) or smaller than normal (Krogman et al., 1975; Smahel et al., 1987). Most authors have reported smaller than normal AP dimensions, indicating some degree of maxillary hypoplasia in individuals older than 11 years (Hayashi et al., 1976; Johnson, 1980; Horswell and Levant, 1988; Smahel and Mullerova, 1995; Ozturk and Cura, 1996; Schultes et al., 2000). One study reported no difference from normal (Dahl, 1970). The causes of abnormal facial morphology in treated cleft individuals may involve one of two factors: intrinsic developmental deficiency or iatrogenic factors introduced by treatment. Some authors (Bishara, 1973; Isiekwe and Sowemimo, 1984; Yoshida et al., 1992) claim that maxillary deficiency in cleft individuals is an intrinsic primary defect.

Oberoi et al., UCLP AND MAXILLARY ADVANCEMENT 43

TABLE 1 Descriptive Statistics*

UCLP Male Female T1 T2 T3

Le Fort I Controls

10 10

6 6

10.7 10.11

13.3 12.9

15.8 15.7

* UCLP 5 unilateral cleft lip and palate; T1, T2, T3 5 time points in years.

Others (Ortiz-Monasterio et al., 1966; Mars and Houston, 1990; Capelozza et al., 1993) have stated that the maxillary deficiency is primarily a result of surgical repair. These citations are illustrative of opposing views and of the difficulties inherent in conducting clinical studies. This study was conducted to delineate factors that may contribute to severe maxillary hypoplasia requiring maxillary advancement surgery in individuals with nonsyndromic UCLP. Early determination regarding the need for such a procedure is important as it influences the timing and type of orthodontic treatment. METHODS Subjects The subjects were collected from the University of California, San Francisco (UCSF), Center for Craniofacial Anomalies computer database using the key words unilateral cleft lip and palate and Le Fort I. All UCLP individuals were included as the beginning sample frame. Sixteen individuals met our inclusion criteria of confirmed diagnosis of nonsyndromic UCLP who required surgical maxillary advancement and had complete clinical records including at least two lateral cephalograms at the chosen time points and for whom a matched control individual of same age, cleft type, and gender with lateral head films was available. The mean ages at the time points were 10.7 years (T1), 13.3 years (T2), and 15.8 years (T3) in the Le Fort group (Table 1). The nonsyndromic matched control group was selected from the same database using the search terms unilateral cleft lip and palate. The matched control group was composed of individuals whose year of birth was within 6 months of the corresponding study individual. The mean ages were 10.11 years at T1, 12.9 years at T2, and 15.7 years at T3 (Table 1). Methods Chart reviews were performed and clinical information gathered and noted for all the study and control individuals. All lateral cephalometric head films had been taken on the same cephalostat, with a magnification of 9.8%. The films were scanned (U Max Power Look 1100; Techville Inc., Dallas, TX), and a total of 53 hard and soft tissue landmarks were digitized using Dolphin Imaging Version 8.2 (Dolphin Imaging and Management Solutions, Canoga Park, CA) software. Thirty-one angular and linear
FIGURE 1 Landmarks measured (refer to Table 2 for abbreviations).

measurements were analyzed (Fig. 1; Table 2). In addition, the maxillo-mandibular relationship was assessed by calculating the difference between mandibular unit length and maxillary unit length. Approval for this study was granted by the Committee on Human Research at UCSF. Statistical Analysis Intraclass correlation measures across 31 variables on repeated measurements showed that the median intraclass correlation was .96, with values ranging from .95 to .98, indicating excellent reliability. The Wilcoxon matched-pairs signed-rank test with 95% confidence interval was used for all cephalometric measurements at all time points. RESULTS Cephalometric Findings The midface length measured from condylion (Co) to the A point was significantly smaller in the Le Fort group at all three time points, ranging from 73 mm at T1 to 80 mm at T3 versus 83 mm at T1 to 89 mm at T3 in the nonsurgical cleft control group. By definition, those who required surgical maxillary advancement had more midface hypoplasia, and this was clear as early as T1 (Fig. 2; Tables 3 through 5). Maxillary unit length (Co-Ans) was 74 mm in the surgery group and 85 mm in the cleft controls at T1. Both groups had a similar increase in the maxillary AP dimensions from T1 to T3 (Fig. 3). The skeletal discrepancy represented by the mandibular and maxillary unit length differences was significantly different between the two groups at all time points: at T1 (p , .01), at T2 (p , .0009), and at T3 (p , .0005). The unit

44 Cleft PalateCraniofacial Journal, January 2008, Vol. 45 No. 1

TABLE 2 Abbreviations, Descriptions, and Definitions of Points and Measurements on Lateral Cephalometric Radiographs
Abbreviation Description Definition

A B ANS PNS Ba Ar Co Me Pg OP PT Po Or S N G SNA N-A SNB N-Pg ANB MP-SN OP-SN FMA Y-axis LFH A-Po Eplane

A point B point Anterior nasal spine Posterior nasal spine Basion Articulare Condylion Menton Pogonion Occlusal plane Pterygomaxillary fissure point Porion Orbitale Sella Nasion Gonion Maxillary prognathism Maxillary prognathism Mandibular prognathism Mandibular prognathism Sagittal jaw relationship Mandibular plane angle Occlusal plane sella-nasion Mandibular plane angle Y-axis Lower face height Lower incisor protrusion Ricketts Eline

Deepest point of curve of maxilla, between anterior nasal spine (ANS) and dental alveolus Most posterior point in the concavity along the anterior border of the symphysis The tip of the anterior nasal spine The tip of the posterior nasal spine Most inferior posterior point of occipital bone at the anterior margin of occipital foramen Posterior border of the condyle Most posterior superior point of the condyle Most inferior point of the symphysis of mandible Most anterior point of the mandible Functional occlusal plane located between the first molars and first bicuspids Intersection of inferior border of foramen rotundum with posterior wall of pterygomaxillary fissure Most superior point of external auditory meatus Lowest point of roof of orbit Center of pituitary fossa of sphenoid bone Intersection of internasal suture with frontonasal suture in the midsagittal plane Most convex point along the inferior border of the Ramus Angle formed between sella, nasion, and A point Linear measurement between nasion perpendicular and A point Angle formed between sella, nasion, and B point Linear measurement between nasion perpendicular and B point Angle formed between A point, nasion, and B point Angle formed between mandibular plane and sella-nasion plane Angle formed between occlusal plane and sella-nasion plane Angle formed between Frankfurt plane and mandibular plane Angle formed between S-Gn and S-N Linear measurement of Ans-Me Linear measurement of lower incisor tip to A-Po line Line between nasal tip and soft tissue chin point

differences in the Le Fort group were 32 mm at T1, 36 mm at T2, and 40 mm at T3, compared with 18 mm, 24 mm, and 28 mm, respectively, in the UCLP controls (Table 6). The maxillary and mandibular unit length differences in the

FIGURE 2 Midface length for Le Fort I and controls.

UCLP controls were similar to the age-matched standards from the Burlington growth study (Thompson and Popovich, 1977). The ANB angle was significantly smaller in the Le Fort group at all three time points, decreasing from 22u to 25u from T1 to T3, compared with 6u and 1.5u in the controls. Both groups showed progressive maxillary deficiency, as the maxilla did not keep up with mandibular growth (Fig. 4). The Wits analysis also showed that the maxilla was more deficient in the Le Fort group at all three time points, changing from 27 mm at T1 to 29 mm at T3, compared with a change from 5 mm at T1 to 1 mm at T3 in the UCLP control group. Mandibular length was slightly greater in the Le Fort group but was not statistically significant, indicating that in most cases, maxillary deficiency and not mandibular prognathism was the cause of the skeletal discrepancy (Fig. 5). The lower incisors in the Le Fort group were significantly more anterior to the A-Po line, resulting from a retruded position of the A point. The upper lip position was significantly farther back from the E plane at all three time points: 26.4 mm at T1 to 27.2 mm at T3, compared with 21.4 mm at T1 and 24.8 mm at T3 in the nonsurgical controls. The saddle angle was significantly smaller in the Le Fort group at T1, but there was no difference observed at T2 and T3.

Oberoi et al., UCLP AND MAXILLARY ADVANCEMENT 45

TABLE 3 Statistical Analysis of Cephalometric Measurements for Le Fort I and Control Groups at T1
95% Confidence Interval 95% Confidence Interval Wilcoxon Signed-Rank p Value

Cranial Base Measurement

Le Fort I

Control

Anterior cranial base Posterior cranial base Saddle angle Sagittal maxillary measurements SNA N-A Midface length Co-A Maxillary unit length Co-Ans Sagittal mandibular measurements SNB N-Pg Mandibular unit length Co-Pog Sagittal jaw relationship measurements ANB Wits Vertical maxillary and mandibular measurements MP-SN OP-SN FMA Y-axis LFH % LFH Dentoalveolar measurements Upper incisorSN Upper incisorAPo Upper incisorNA Upper incisorNA (mm) Lower incisorMP Lower incisorAPo Lower incisorNB Lower incisorNB (mm) Interincisal angle Soft tissue measurements Upper lip to E plane Lower lip to E plane Nasolabial angle Chin angle
* p , .05.

63.37 (3.09) 30.31 (3.97) 116.11 (4.05) 80.94 22.40 73.26 74.90 (3.62) (3.11) (4.46) (3.88)

60.50 to 66.23 26.63 to 33.98 112.36 to 119.86 77.58 25.28 69.13 71.31 to to to to 84.29 0.48 77.38 78.49

67.65 (3.72) 32.80 (2.22) 122.17 (3.77) 84.14 0.44 82.90 85.07 (4.28) (4.4) (3.93 ) (3.48)

64.21 to 71.09 30.74 to 34.85 118.68 to 125.66 80.18 23.64 79.26 81.85 to to to to 88.10 4.52 86.53 88.29

.078 .171 .031* .687 .687 .031* .015* .109 .218 .375 .046* .015* .046* .578 .015* 1.00 .156 .156 .296 1.00 .078 .015* .937 .031* .468 .812 .937 .015* .468 .812 .109

82.84 (4.64) 21.57 (5.19) 105.47 (5.73) 21.90 (3.71) 27.31 (4.83) 36.71 14.83 37.06 66.71 67.31 59.50 100.26 1.09 19.34 2.89 38.10 3.51 18.36 3.01 144.20 26.49 20.11 105.97 67.10 (3.39) (5.81) (6.44) (3.89) (3.52) (3.14) (9.79) (3.01) (9.64) (2.91) (3.36) (2.39) (6.58) (1.75) (5.95) (1.72) (2.70) (8.13) (7.04)

78.55 to 87.14 26.37 to 3.23 100.17 to 110.77 25.33 to 1.53 211.78 to 22.85 33.58 9.45 31.10 62.17 64.05 56.60 to to to to to to 39.85 20.21 43.01 70.33 70.57 62.40

78.05 (2.88) 28.18 (6.34 ) 100.80 (5.84) 6.11 (3.12) 4.84 (2.94) 31.14 12.28 28.08 66.64 64.54 57.28 93.80 1.71 9.67 22.71 38.02 20.41 21.04 3.07 143.20 21.42 1.01 108.08 74.14 (4.24) (4.22) (3.70) (1.32) (6.61) (2.95) (10.90) (3.65) (8.47) (1.75) (1.77) (2.06) (5.4) (1.58) (13.00) (2.1) (1.51) (10.83) (6.04)

75.39 to 80.72 214.05 to 22.31 95.39 to 106.20 3.22 to 9.00 2.12 to 7.56 27.21 8.38 24.65 65.41 58.42 54.55 83.71 21.66 1.83 24.33 36.39 22.31 16.01 1.60 131.17 20.41 20.38 98.09 68.54 to to to to to to to to to to to to to to to to to to to 35.06 16.19 31.51 67.86 70.65 60.01 103.88 5.09 17.51 21.08 39.66 1.49 26.06 4.53 155.22 0.55 2.41 118.10 79.73

91.20 to 109.31 21.70 to 3.87 10.42 to 28.26 0.20 to 5.57 34.99 to 41.21 1.30 to 5.72 12.27 to 24.44 1.393 to 4.64 138.70 to 149.70 28.08 22.61 98.45 60.59 to to to to 4.89 2.38 113.49 73.61

The mandibular plane angle was significantly steeper in the Le Fort group at T1, but this trend did not continue at T2 and T3. However, the mandibular plane angle was steeper in both groups as compared with normal values in noncleft individuals. Clinical Findings There was a higher incidence of missing maxillary teeth in the Le Fort group, with almost twice the number missing as compared with the cleft controls (p , .05). In both groups, 54% of the missing teeth were lateral incisors, all on the cleft side. There were more missing teeth outside the cleft in the Le Fort group (46%) compared with the UCLP controls (6%). The most commonly missing tooth was the maxillary second premolar, twice more commonly missing on the right (21%) than on the left side (10%). There was a greater average number of surgical procedures in the Le Fort group (3.5), compared with

2.25 in the UCLP controls (p , .05). These were primarily secondary palate procedures and fistula repairs. Four of the Le Fort individuals had a pharyngeal flap combined with the primary palate repair, and all had secondary palate procedures, including secondary pharyngeal flaps in four individuals. Only 2 of the 16 Le Fort individuals had their initial lip and palate repair by the team surgeon. In the control group, only one individual had a secondary pharyngeal flap. The team surgical procedure for palate repair was predominantly the Furlow z-plasty, completed before 1 year of age. In the Le Fort group, only two individuals had consistent team care from infancy, while the others came to the team at various ages. Eight of the matched UCLP controls had consistent team care from infancy, and all were in consistent team care after the age of 9 years. All individuals had orthodontic treatment, but phase 1 treatment was provided only to those who had team care at the appropriate age. The mean age for the orthodontic

46 Cleft PalateCraniofacial Journal, January 2008, Vol. 45 No. 1

TABLE 4 Statistical Analysis of Cephalometric Measurements for Le Fort I and Control Groups at T2
95% Confidence Interval 95% Confidence Interval Wilcoxon Signed-Rank p Value

Cranial Base Measurement

Le Fort I

Control

Anterior cranial base Posterior cranial base Saddle angle Sagittal maxillary measurements SNA N-A Midface length Co-A Maxillary unit length Co-Ans Sagittal mandibular measurements SNB N-Pg Mandibular unit length Co-Pog Sagittal jaw relationship measurements ANB Wits Vertical maxillary and mandibular measurements MP-SN OP-SN FMA Y-axis LFH % LFH Dentoalveolar measurements Upper incisorSN Upper incisorAPo Upper incisorNA Upper incisorNA (mm) Lower incisorMP Lower incisorAPo Lower incisorNB Lower incisorNB (mm) Interincisal angle Soft tissue measurements Upper lip to E plane Lower lip to E plane Nasolabial angle Chin angle
* p , .05.

67.46 (3.77) 35.08 (5.15) 122.65 (8.10) 78.06 24.79 79.87 81.81 (4.60) (5.06) (4.89) (4.91)

65.29 to 69.64 32.11 to 38.05 117.97 to 127.33 75.40 27.72 77.05 78.90 to to to to 80.71 21.87 82.70 84.65

69.91 (4.00) 34.32 (4.01) 124.89 (5.96) 81.29 21.51 86.34 88.50 (3.49) (3.99) (4.89) (4.95)

67.60 to 72.22 32.01 to 63.64 121.45 to 128.33 79.27 23.81 83.51 85.64 to to to to 83.30 0.79 89.16 91.36

.173 .903 .542 .035* .009* .000* .001* .079 .068 .065 .001* .000* .400 .808 .153 .426 .148 .068 .453 .262 .153 .002* .289 .013* .964 .583 .867 .000* .952 .241 .001*

82.06 (4.91) 20.61 (9.85) 115.14 (4.59) 23.99 (4.28) 26.96 (5.28) 37.25 12.26 34.86 66.84 70.89 59.00 104.96 2.18 26.89 6.01 41.64 5.79 21.15 4.54 135.96 27.08 1.38 96.19 65.09 (4.95) (8.43) (6.22) (4.17) (4.18) (3.50) (8.77) (2.77) (10.96) (4.52) (3.77) (3.26) (7.23) (2.88) (9.16) (3.35) (3.33) (12.74) (5.05)

79.23 to 84.89 26.30 to 5.08 112.49 to 117.79 26.47 to 21.52 210.01 to 23.92 34.39 7.40 31.27 64.43 68.48 56.98 99.90 0.58 20.56 3.40 39.47 3.90 16.98 2.88 130.67 29.01 20.54 88.83 62.17 to to to to to to to to to to to to to to to to to to to 40.11 17.13 38.46 69.25 73.31 61.02 110.03 3.78 33.21 8.63 43.82 7.67 25.32 6.20 141.25 25.15 3.30 103.54 68.00

78.18 (3.68) 27.42 (9.08) 110.22 (8.08) 3.11 (2.51) 1.13 (2.19) 34.86 14.06 30.57 68.01 68.33 57.10 101.43 3.03 20.14 1.08 40.36 1.86 21.24 4.14 135.51 22.53 1.49 90.03 72.36 (6.36) (5.04) (6.41) (3.11) (4.93) (2.21) (9.52) (1.72) (9.06) (2.68) (3.78) (2.80) (5.03) (2.24) (8.18) (2.35) (2.93) (13.80) (5.56)

76.05 to 80.30 212.67 to 22.18 105.56 to 114.88 1.66 to 4.57 20.14 to 2.40 31.20 11.15 26.87 66.22 65.48 55.82 95.93 2.04 14.91 20.47 38.18 0.25 18.33 2.84 130.78 23.88 20.20 82.06 69.15 to to to to to to to to to to to to to to to to to to to 38.53 16.97 34.27 69.81 71.18 58.38 106.93 4.03 25.37 2.63 42.54 3.48 24.14 5.43 140.23 21.17 3.17 98.00 75.58

intervention was 15 years in the Le Fort group versus 9 years in the controls. To address the question as to whether the UCLP nonLe Fort surgery controls had maxillary development within the normal range, we compared the maxillary and mandibular measurements at T3 with normative data for noncleft individuals from the Burlington Growth Study (Thompson and Popovich, 1977). Maxillary unit length, SNA, SNB, and ANB for the nonsurgical cleft controls were close to the norms for the noncleft controls (Table 7). DISCUSSION This study was designed to delineate features that characterize and may contribute to maxillary hypoplasia in nonsyndromic individuals with UCLP. It is well recognized that individuals with repaired UCLP show variation in the degree of maxillary hypoplasia. A certain number will require surgery to advance the maxilla. This

number varies among studies, and the morphologic and functional characteristics used to determine the need for maxillary surgery are not well defined. In a large Toronto sample of UCLP adult males, Ross (1987) noted that orthognathic surgery would be necessary in 25% of the sample to achieve adequate functional relation of the jaws, harmonious facial esthetics, or both. In an outcomes study from the United Kingdom on 218 UCLP patients (Williams et al., 2001), 70% of the patients had midface retrusion at age 12, and 40% of these would eventually require orthognathic surgery to correct the skeletal discrepancy. In a long-term retrospective outcome assessment of facial growth (Rosenstein et al., 2003), the incidence of orthognathic surgery was 18.29%. At our center, 14% of all individuals with nonsyndromic UCLP born between 1971 and 1990 had Le Fort I surgical advancement. In our study sample of Le Fort patients, significant midface hypoplasia was documented at the first time point and became more marked toward the end of growth. When

Oberoi et al., UCLP AND MAXILLARY ADVANCEMENT 47

TABLE 5 Statistical Analysis of Cephalometric Measurements for Le Fort I and Control Groups at T3
95% Confidence Interval 95% Confidence Interval Wilcoxon Signed-Rank p Value

Cranial Base Measurement

Le Fort I

Control

Anterior cranial base Posterior cranial base Saddle angle Sagittal maxillary measurements SNA N-A Midface length Co-A Maxillary unit length Co-Ans Sagittal mandibular measurements SNB N-Pg Mandibular unit length Co-Pog Sagittal jaw relationship measurements ANB Wits

68.33 (5.17) 35.06 (5.79) 123.10 (5.89) 76.93 26.26 79.95 82.36 (4.93) (5.10) (5.09) (5.06)

65.35 to 71.31 31.72 to 38.41 119.70 to 126.50 74.08 29.20 77.01 79.44 to to to to 79.77 23.31 82.89 85.28

71.46 (5.83) 36.48 (3.74) 121.98 (6.55) 80.43 22.90 86.34 88.46 (5.97) (6.25) (6.54) (6.66)

68.09 to 74.83 34.32 to 38.64 118.20 to 125.76 76.98 26.51 82.56 84.61 to to to to 83.87 0.71 90.11 92.30

.135 .247 .987 .194 .178 .000* .000* .210 .119 .068 .000* .000* .391 .622 .122 .626 .334 .131 .761 .153 .670 .101 .391 .011* .087 1.000 .808 .038* .715 .426 .020*

81.56 (4.25) 20.71 (8.75) 119.91 (8.47) 24.64 (3.92) 28.81 (6.26)

79.10 to 84.01 25.76 to 4.34 115.02 to 124.81 26.90 to 22.38 212.43 to 25.20 33.80 7.81 31.81 64.78 70.48 57.85 103.46 0.89 26.43 5.61 40.13 4.20 18.29 2.66 123.05 28.86 21.09 87.45 59.43 to to to to to to to to to to to to to to to to to to to 39.83 18.84 37.95 70.60 79.79 60.81 112.02 5.37 35.21 10.57 45.07 7.76 28.11 6.85 138.15 25.66 2.59 108.83 67.54

78.94 (6.01) 26.47 (11.98) 115.17 (8.94) 1.49 (3.35) 1.04 (4.51) 34.22 11.46 30.30 68.26 72.91 57.97 109.13 5.36 28.69 4.96 43.90 2.76 19.38 4.47 130.41 24.84 0.44 92.60 71.15 (7.18) (5.66) (7.22) (4.50) (6.57) (2.84) (8.93) (3.06) (8.36) (3.79) (3.98) (2.63) (5.82) (2.06) (7.85) (3.43) (3.14) (15.44) (4.88)

75.47 to 82.41 213.39 to 0.44 110.01 to 120.33 20.44 to 3.43 21.57 to 3.64 30.07 8.19 26.13 65.67 69.12 56.33 103.97 3.60 23.86 2.78 41.60 1.25 16.02 3.28 125.88 26.82 21.38 83.69 68.33 to to to to to to to to to to to to to to to to to to to 38.37 14.72 34.47 70.86 76.71 59.61 114.28 7.13 33.51 7.15 46.20 4.28 22.74 5.66 134.95 22.85 2.25 101.51 73.97

Vertical maxillary and mandibular measurements MP-SN 36.81 (5.23) OP-SN 13.32 (9.55) FMA 34.88 (5.32) Y-axis 67.69 (5.04) LFH 75.14 (8.07) % LFH 59.33 (2.57) Dentoalveolar measurements Upper incisorSN Upper incisorAPo Upper incisorNA Upper incisorNA (mm) Lower incisorMP Lower incisorAPo Lower incisorNB Lower incisorNB (mm) Interincisal angle Soft tissue measurements Upper lip to E plane Lower lip to E plane Nasolabial angle Chin angle
* p , .05.

107.74 3.13 30.82 8.09 42.60 5.98 23.20 4.76 130.60 27.26 0.75 98.15 63.49

(7.41) (3.88) (7.60) (4.29) (4.28) (3.09) (8.50) (3.63) (13.08) (2.77) (3.18) (18.51) (7.02)

we assessed the maxillo-mandibular relationship, it was clear that the need for maxillary surgery could be determined as early as 10 to 12 years of age and possibly earlier. The difference between mandibular unit length and maxillary unit length is a good indicator of jaw size relationship. In the Le Fort group, the average difference was 32 mm at T1, 36 mm at T2, and 40 mm at T3, significantly larger than the differences in the UCLP control group at 18 mm, 24 mm, and 28 mm at T1, T2, and T3, respectively (Table 6). The unit difference of 32 mm in the 10- to 12-year group was well outside the normal range and would predict the need for maxillary advancement surgery. Based on Harvolds analysis of data from the Burlington Growth Study (Proffit et al., 2003), a jaw size discrepancy with a mandibular length more than 30 mm greater than maxillary length will require surgical correction. There was a higher incidence of missing teeth in the Le Fort group, with almost twice the number missing as compared with the cleft controls. Shapira et al. (2000) have

shown the presence of hypodontia in 77% of individuals with nonsyndromic cleft lip and palate. They also found that maxillary permanent lateral incisors were the teeth most frequently missing (74%) on the cleft side, followed by the maxillary and mandibular second premolars, similar to our finding. The larger number of missing teeth in the maxilla contributes to a smaller dental arch. This is an intrinsic tissue deficiency factor. On average, the Le Fort group had a larger number of palatal surgical procedures, including four primary and four secondary pharyngeal flaps. Every surgical procedure results in scarring. A pharyngeal flap ties the soft palate to the posterior pharyngeal wall. In our study, it was apparent that the individuals who had primary and early secondary pharyngeal flaps had significant maxillary hypoplasia. The literature is inconsistent on the effects of pharyngeal flaps on maxillary growth (Keller et al., 1988; Semb and Shaw, 1990). In our sample, it appeared to be a significant contributing factor.

48 Cleft PalateCraniofacial Journal, January 2008, Vol. 45 No. 1

FIGURE 3 Maxillary unit length for Le Fort I and controls.

FIGURE 4 ANB angle for Le Fort I and controls.

The fact that early orthodontic expansion was not provided for most of the Le Fort individuals must also be considered a contributing factor to the growth differences between the two groups. Consistent team care will ensure that procedures such as maxillary expansion are done at the appropriate time. Although not discussed here, team care is also essential for many other reasons such as family support, feeding, speech, genetics, and family planning. SUMMARY AND CONCLUSIONS Based on our findings, the need for maxillary advancement surgery can be determined as early as 10 to 12 years of age by the degree of jaw size discrepancy, as measured by mandibular/maxillary unit length difference and the AP position of the maxilla. Factors contributing to severe maxillary hypoplasia can be congenitally missing teeth, primary or early pharyngeal flap surgery, repeat palate surgeries and delayed orthodontic intervention, and iatrogenic factors associated with absent or inconsistent team care. Consistent team care with a minimum number of
FIGURE 5 Mandibular unit length for Le Fort I and controls. TABLE 6 Comparison of Unit Length Difference in Le Fort and Control Groups at All 3 Time Points
Unit Length Difference (mm) Time Point Le Fort I Control p Value

TABLE 7 Comparison of Maxillary Measurements in Nonsurgical Unilateral Cleft Lip and Palate (UCLP) and Noncleft Controls
Maxillary Measurement Nonsurgical UCLP Noncleft Controls

T1 T2 T3

32 36 40

18 24 28

,.01 ,.0009 ,.0005

Maxillary unit length (mm) SNA (u) SNB (u) ANB (u)

88.5 80.5 79 1.5

94 81 78 3.0

Oberoi et al., UCLP AND MAXILLARY ADVANCEMENT 49

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