Original Article

The Cleft Palate-Craniofacial Journal

2019, Vol. 56(1) 15-20
Evaluation of Nasal Airway Volume of ª 2018, American Cleft Palate-
Craniofacial Association

Operated Unilateral Cleft Lip and Palate Article reuse guidelines:

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DOI: 10.1177/1055665618774024
Patients Compared With Skeletal journals.sagepub.com/home/cpc

Class III Individuals

Ümit Ertaş, DDS, PhD1 and Mert Ataol, DDS, PhD1

Abstract
Cleft lip and palate (CLP) patients have various problems with nasal anatomy beyond just oronasal separation. The alar base,
concha, and septum are over impressed in these individuals. Additionally, skeletal class III deformity is seen. These conditions may
limit nasal function. In our study, 15 unilateral patients with CLP older than 15 years (10 females, 5 males; mean age: 19.13) who
had received surgery were included as the study group, and 15 participants with noncleft skeletal class III deformities were
included as the control group (10 females, 5 males; mean age: 19.20). The individuals’ nasal airway volumes (total/cleft side/
noncleft side/control/ nasal passages) were examined and compared statistically. The results showed that the study group had
significantly higher values in terms of total airway volume (P < .05). Additionally, there were significant differences between the
cleft side and noncleft side volumes, between the cleft side volumes and the volumes of the control group participants, and
between the noncleft side volumes and the volumes of the control group participants (P < .05). There was no difference between
the groups in terms of nasopharyngeal (P ¼ .39) and nasal passage volumes (P ¼ .73). The results show there are some problems
regarding nasal airway volume in patients with CLP, even when lip, palate, and alveolar cleft operations have been performed. The
aim of this study was to evaluate differentiation of nasal airway volumes between unilateral patients with CLP and individuals with
noncleft skeletal class III serving as the control group.

Keywords
unilateral cleft lip and palate, nasal airway, upper airway, cone beam computed tomography

Introduction defect, surgical disturbance, abnormal lip tension, and growth-

Patients with cleft lip and palate (CLP) not only have oronasal
separation deficiency but also have various nasal anatomy
problems. All lip and palate clefts, even a mild incomplete
unilateral cleft lip, can be associated with nasal deformity of
varying degrees. Characteristic features of unilateral cleft lip
and palate (UCLP) patients are having a wide alar base and
separated lip segments on the cleft side, an increased alar rim,
an oblique columella, a deviated septum, and an overhanging
nostril apex (Berkowitz, 2006).
These features result from a combination of anatomical
abnormalities, surgical scarring due to previous operations, addi-
tional septal deformities of other internal nasal structures, malfor-
mation of the nasal tip, and malposition of alar cartilages (Vass
et al., 2016). Additionally, a skeletal class III relationship is widely
seen in CLP individuals. Although the leading causes of class III
malocclusion in non-CLP individuals are hereditary, multiple fac-
tors contribute for CLP individuals, including genetics, local cleft
related problems (Lin et al., 2016; Shetye, 2016).
The aim of this study was to evaluate differentiation of nasal
airway volumes between UCLP patients and individuals with
noncleft skeletal class III serving as the control group.
For evaluating upper airway volumes, cone beam com-
puted tomography (CBCT) is known to provide more accurate
data than lateral cephalography (Aboudara et al., 2009; Aras
et al., 2012). It is possible to measure upper airway volume
with various software using CBCT. In a study evaluating the
reliability of various software for calculating upper airway
1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk
University, Erzurum, Turkey
Corresponding Author:
Mert Ataol, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Mersin University, Mersin 33343, Turkey.
E-mail: ataolmert@gmail.com
16
Table 1. Definitions of Boundaries.
Anterior Posterior
Spaces Boundary Boundary Inferior Boundary
Nasal cavity From ANS to From S to PNS From ANS to PNS
the apex of
the nasal
bone
Nasal sides: Outline of nasal cavity in section containing maxillary first molar bifurcation from crista galli to the nasal floor Excluding the
coronal following the sidewalls of the right and left nasal cavity
plane
Nasopharynx From S to PNS From S to the Ba From PNS to Ba
Nasal From ANS to PNS,
passage extending to
posterior
pharyngeal wall
Abbreviations: ANS, anterior nasal spine point; Ba; basion point; N, nasion point; PNS, posterior nasal spine point; S, sella point.
volume, Dolphin 3D software (Dolphin Imaging and Manage-
ment Solutions, California) was found to be one of the most
reliable with a 1% error margin (Weissheimer et al., 2012).
Similarly, El and Palomo (2010) evaluated Dolphin 3D soft-
ware for the measurement of nasal passage volume and found
it successful.
In the available literature, studies evaluating UCLP patients
often compare them with individuals who have skeletal class I
relationship, using them as the control group (Aras et al., 2012;
Celikoglu et al., 2014; Gohilot et al., 2014; Pimenta et al.,
2015). However, it would be more appropriate to compare
these patients with skeletal class III individuals because indi-
viduals with CLP also have commonly skeletal class III rela-
tionships (Tinano et al., 2015; Lin et al., 2016). To clearly
understand, the differences in internal nasal morphology
between UCLP and noncleft skeletal class III individuals will
be helpful in diagnosis and treatment planning.
Material and Methods
This study used 15 CBCT images of operated UCLP patients
and were older than 15 years of age (10 females, 5 males;
average age: 19.13), and 15 CBCT images of the skeletal class
III control group participants who have no cleft and corre-
sponded in age and sex to the study group (10 females, 5 males;
average age: 19.20). The previously operated UCLP patients
had received a CBCT examination for postoperative evaluation
or planning of reconstructive surgery and patients who had
skeletal class III relationship was included. The CBCT data for
the control participants had been obtained during routine radio-
graphic documentation for different reasons. Individuals who
had any syndrome or craniofacial anomaly, acute or chronic
upper airway infections, nasal or orthognathic surgery history,
palatal expansion history, or pharyngeal and nasal pathologies
such as tonsillitis or polyposis were excluded from the study.
Ethical approval was obtained from the local ethics committee
of Atatürk University Faculty of Dentistry, and the principles
outlined in the Declaration of Helsinki were followed.
The Cleft Palate-Craniofacial Journal 56(1)
Lateral
Superior Boundary Boundary
From N to S Excluding the
sinuses
sinuses
Parallel to the inferior boundary passing through Excluding the
the last slice before the nasal septum fused with sinuses
the posterior wall of the pharynx
All CBCT scans were acquired at supine position. The
obtained data were analyzed using Dolphin 3D Imaging Soft-
ware Version 11.9. Nasal airway volume, nasopharyngeal air-
way volume, and nasal passage volume were assessed
separately, excluding the sinus areas. Additionally, nasal-side
volume was assessed for the cleft side and the noncleft side of
the UCLP patients, while the mean nasal-side volume of the
right and left side of the control group participants was
assessed. The threshold was defined manually in an attempt
to include airway spaces and to remove any visible extraneous
scatter, artifacts, and background.
The nasal and nasopharyngeal airway measurements were
taken from the CBCT images according to Glupker et al
(2015). Nasal passage volumes were taken according to El and
Palomo (2010). The boundaries of these areas were described
and shown in Table 1 and Figure 1, respectively. After defining
the boundaries and threshold, each volume was calculated in
cm3 according to the manufacturer’s recommendations (Fig-
ures 2 and 3).
Statistical analysis was performed using SPSS 19.0 soft-
ware. The Kolmogorov-Smirnov test was used for normality,
and the Student t test was used to determine the differences
between the groups. P values of “<.05” were considered
statistically significant.
Results
The present study sample consisted of 30 CBCT images taken
from 15 patients with UCLP and 15 control participants. There
were no significant differences between the UCLP and non-
CLP control groups in terms of age and sex.
The volumes of nasal, nasopharyngeal, and nasal passage
airways are shown in Table 2. The mean nasal volume for the
UCLP patients was 22.45 cm3, whereas the mean for the con-
trol group participants was 16.64 cm3. These results showed
that the total nasal volume of the UCLP patients was signifi-
cantly larger than of the skeletal class III control group parti-
cipants (P ¼ 0.00). However, in terms of nasopharyngeal and
Ertaş and Ataol 17

Figure 1. Boundaries of nasal, nasopharyngeal, and nasal passage areas on midsagittal plane.

Figure 2. Total nasal cavity and nasal side measurements of a unilateral cleft lip and palate (UCLP) patient.
18 The Cleft Palate-Craniofacial Journal 56(1)

Figure 3. Total nasal cavity and nasal side measurements of a skeletal class III individual.

Table 2. Total Airway Volumes. Table 3. Nasal Side Airway Volumes.

UCLP Control UCLP Control

Mean (SD) Mean (SD) Noncleft Control Cleft/ Cleft/ Noncleft/

Cleft side Side (mean) Noncleft Control Control
Nasal 22.45 (4.20) 16.64 (2.61)
Nasopharyngeal 4.87 (1.41) 4.37 (1.70) Mean (SD) Mean (SD) Mean (SD) (P) (P) (P)
Nasal passage 12.64 (2.29) 12.30 (2.95)
10.06 (2.66) 12.38 (2.24) 8.31 (1.30) .016 .034 .000
Abbreviations: SD, standard deviation; UCLP, unilateral cleft lip and palate.
Abbreviations: SD, standard deviation; UCLP, unilateral cleft lip and palate.

nasal passage volumes, there was no statistically significant

difference between the groups.
The volumes of the noncleft side of the UCLP patients’
nasal airways (12.38 cm3) were larger than both the volumes
of the cleft side of the UCLP patients’ nasal airways (10.06
cm3) and the means of the left and right sides of the control
group participants’ nasal airways (8.31 cm3). In the binary
comparison of groups, there was a significant difference for all
3 comparisons (Table 3).
Discussion
Drake et al. (1993) indicated that age is a strong determinant of
the nasal airway dimensions of cleft patients. Maxillary growth
is considerably associated with the activities of sutures and
synchondroses. The last closed synchondrosis, spheno-
occipital synchondrosis, loses its effectiveness after 15 years
of age (Bassed et al., 2010). For this reason, to ignore the
effects of growth, we included patients who were over 15.
Normal bone development is often explained by functional
matrix theory that is muscle, nerve, glands, teeth, neurocranial
fossa, and nasal, orbital, oral, and pharyngeal cavities are pri-
mary determinants of skeletal developments, while skeletal
units are secondary (Berkowitz, 2006). Various disorders that
occur in this process manifest themselves in various types, such
as the etiopathogenesis of maxillary deficiency in UCLP and
noncleft individuals have different character (Lin et al., 2016).
Etiopathogenesis of maxillary deficiency in noncleft skeletal
class III relationship can be genetic or environmental (Ngan
et al., 1997), and maxillary deficiency may be implicated in this
situation (Singh, 1999). On the other hand, clefts are hereditary
and congenital anomalies that are referred to as nonsyndromic
and syndromic, based on their association with other anoma-
lies. About 50% of CP and 10% of CLP are associated with a
syndrome (Berkowitz, 2006).
Patients with CLP have varying degrees of skeletal class III
deformities caused by a combination of surgical repair, palatal
Ertaş and Ataol
muscle strength, scar contracture, and congenital malforma-
tions (Williams et al., 2001; Lin et al., 2016; Shetye, 2016).
Clinically, patients with CLP often present with a concave
profile, midface deficiency, and skeletal class III relationship.
The maxilla may also be deficient in the transverse and vertical
planes, and there may be reduced midface height, constricted
maxillary posterior arch width, and anterior or posterior cross
bite. The extent of abnormal midface growth varies from mild
to severe (Shetye, 2016). Nasal deformities are quite common
in patients with CLP and affect the size of the nasal cavity and
nasal respiration (Reiser et al., 2011).
Trindade et al. (2015) evaluated the nasal airways of chil-
dren with UCLP using acoustic rhinometry and showed that the
UCLP children had narrower nasal cross-sectional areas than
the noncleft children. Imamura et al. (2002) and Gohilot et al.
(2014) reported that, when compared to a control group of
noncleft skeletal class I participants, UCLP children and ado-
lescents had a more retruded positioned maxilla and had nar-
rowed nasal airway volume.
Aras et al. (2012) and Ölmez-Gürlen et al. (2015) evaluated
the differences in nasal passage volume between UCLP
patients and noncleft individuals using similar boundaries than
our study. Their results showed that there was a statistically
significant difference. However, our results did not correlate
with their results. This may be due to different control group
characteristics.
Previous comparative CLP studies have enrolled non-CLP
participants with normal occlusion participants as the control
group, and comparisons may have been made between class III
patients with CLP and class I normal controls (Aras et al., 2012;
Celikoglu et al., 2014; Gohilot et al., 2014; Pimenta et al.,
2015). To our knowledge, no previous studies evaluating the
nasal volume of UCLP patients correlated with skeletal class
III participants have been published.
Lin et al. (2016) compared 30 UCLP children who had
received operations with 30 noncleft skeletal class III children
in terms of facial hard and soft tissue properties using lateral
cephalograph. They demonstrated that the intermaxillary rela-
tionship was similar for the 2 groups, but both the maxilla and
mandible were more posteriorly positioned in the UCLP group
than in the control group. This situation revealed a 2-dimen-
sional similarity between the 2 groups and was confirmed by
another study (Tinano et al., 2015).
In our study, we revealed that the 3-dimensional nasal vol-
ume of the UCLP patients was significantly larger than for the
skeletal class III control group participants (P ¼ .00). It was
expected that our study group and control group would have
similar nasal cavity volumes. Although the skeletal relation-
ships were similar, the reason for the significant difference
between the groups may be degeneration of internal nasal
structures, such as septum and conchae (Bassed et al., 2010)
There was no difference between the 2 groups in terms of
nasopharyngeal and nasal passage volumes. These measure-
ments may be related more to the size and position of the
maxilla rather than internal nasal structures.
19
For patients with CLP, septal deformity and deviation are
very high, and the deviations are toward the cleft side
(Sandham and Murray, 1993). There is no previous study
in the literature that compares nasal side volumes using
3 dimensional (3-D) methods. Trindade et al. (2015) eval-
uated the nasal sides of UCLP children with acoustic rhino-
metry and reported that the volumes of the cleft side was
significantly smaller than both the volumes of the noncleft
side and the volumes found in the control group. In a sim-
ilar study, Kunkel et al. (1999) and Mani et al. (2010)
showed that the volumes of the cleft side was significantly
smaller than noncleft side of UCLP patients. On the other
hand, in a CBCT study, Farzal et al. (2016) revealed that
there was not a statistically significant difference between
cleft side and noncleft side of UCLP patients, although they
observed lower cleft side volume.
Our 3-D evaluation results showed that the noncleft side is
statistically significantly wider than both the cleft side and
those in the control. In our study, the volumes of the noncleft
side in the UCLP patients’ nasal airways (12.3 cm3) were larger
than both the cleft side volumes (10.06 cm3) and the mean
volumes of the left and right side of control group participants’
nasal airways (8.31 cm3), respectively.
Many researchers working on nasal function and the anat-
omy of patients with cleft base their work on subjective data,
such as clinical evaluation or patient experience. However, it is
essential to use objective assessments and to correlate these
findings with objective data in order to plan treatment protocol
(Mani et al., 2010).
Conclusion
Understanding the differences in craniofacial morphology
between UCLP and non-CLP individuals with a skeletal class
III relationship will help oral and maxillofacial surgeons and
other members of the CLP team. The results showed that there
are some problems in terms of nasal airway volume in patients
with CLP even if lip, palate, and alveolar cleft surgeries were
performed. For this reason, corrective nasal surgical procedures
should not be restricted to aesthetic procedures alone.
Authors’ Note
This study was presented as an oral presentation at 22nd BaSS
Congress, May 4-6, 2017, Thessaloniki, Greece. Mert Ataol is now
affiliated to Department of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Mersin University, Mersin, Turkey.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
20
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