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Keywords:

  • adult;
  • cleft palate;
  • growth and development;
  • maxilla

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion and conclusions
  7. References

Patients with cleft left lip and palate (CLP) normally require extensive surgery from an early age up to the end of adolescence. These surgeries affect the growth of the maxillofacial complex. The degree to which the cleft itself affects growth of the maxillofacial complex remains poorly understood. By analysing the width and elevation of the palatal shelves in unoperated adolescents and adults with unilateral and bilateral cleft lip and palate (UCLP and BCLP, respectively) and a non-cleft control group, it is possible to gain more insight into the real intrinsic growth potential of the maxillary structures. In this study, dental casts of the full permanent dentition of individuals with unrepaired UCLP (= 68) and BCLP (= 13) and non-cleft controls (= 24) from the same area of Indonesia were digitized three-dimensionally. Maxillary arch width in the canine, premolar and molar regions, and the width and elevation of the palatal shelves were measured. Results showed that in patients with UCLP, the width of the palatal shelves on the cleft side in all regions, and on the non-cleft side in the canine/first premolar region, was significantly smaller compared with the control group. BCLP subjects showed similar deviations. In the UCLP group, the palatal shelves were rotated cranially and positioned more vertically. In the BCLP group, the palatal shelves were inclined by almost 10 ° more than the control group. The width of the palatal shelf and width of the maxillary arch positively correlated in the canine and first premolar regions for both the cleft and non-cleft side in patients with UCLP, and in the canine region for patients with BCLP. This means that the wider the palatal shelf, the wider the maxillary arch. The elevation of palatal shelves correlated with the maxillary arch width in all regions in patients with UCLP, and only in the premolar region in the control group. Thus, the wider the arch width, the smaller the elevation angle (the maxillary shelves are less vertical). No correlations between palatal shelf elevation and maxillary arch width were found in the BCLP group. This shows that the intrinsic growth potential in patients with UCLP and BCLP is affected by a smaller palatal shelf width and larger elevation of the shelves. These deviations may result in a wider cleft.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion and conclusions
  7. References

One of the major problems in the treatment of cleft lip and palate is disturbance of maxillary growth. To what degree the abnormal maxillary growth is related to an intrinsic primary defect vs. a secondary effect of iatrogenic factors such as surgical repair in early childhood or orthodontic treatment is not fully understood. Dahl (1970) and Bishara (1973) suggested that there are significant differences in dentofacial relationships of patients with untreated unilateral complete cleft lip, alveolus and palate (UCLP) compared with non-cleft subjects. The effect of the lip and/or palate surgery is therefore assumed to be superimposed on intrinsic deficiencies of the dentofacial structures.

In general, studies on facial growth in patients with cleft lip and palate (CLP) are mainly carried out on patients who have already undergone operations for repair of the cleft in early childhood (Mazaheri et al. 1967; Heidbüchel et al. 1994; Heidbüchel & Kuijpers-Jagtman, 1997). In an attempt to estimate the effect of surgery and the effect of various types of clefts on subsequent facial growth, several research groups studied dental and facial development in unoperated adolescent and adult cleft patients whose dentofacial growth and development of the maxillary arch was assumed to be undisturbed (Innis, 1962; Bishara et al. 1976, 1985, 1986; Hardjowasito & Latief, 1988; Hardjowasito, 1989; Capelozza Filho et al. 1996). Though the results are not always consistent and these studies were performed in different ethnic populations (Lambrecht et al. 2000), investigations on maxillofacial growth and arch development in untreated patients with clefts lead to the conclusion that surgery must be considered a major causative factor of maxillary retrusion once patients are surgically treated (Ortiz-Monasterio et al. 1959, 1966; Mestre et al. 1960; Schweckendiek, 1978; Lambrecht et al. 2000; Latief et al. 2010; Ye et al. 2010).

The amount of available palatal tissue and the position of the palatal shelves play a role in the planning of the surgical repair of the cleft. Whether the amount of available palatal tissue is also affected in cleft patients is still controversial. Veau (1931) already suggested that the palatal tissue is principally normal or, if less than normal, patients may have the ability to reproduce the normal amount of palatal tissue during growth. Mars & Houston (1990) also stated that patients with clefts potentially have a normal maxillary development, and Van Limborg (1964) assumed that growth deviations in individuals with clefts are not intrinsic to the cleft itself, but are a secondary effect that is specific for a certain type of cleft. However, Lo et al. (2003) studied the surface area of the palate in four different groups of cleft patients at 3 months of age prior to any surgical intervention using three-dimensional computed tomography images of dental casts; he found that, compared with cleft lip or cleft palate only patients, there is an intrinsic tissue deficiency in the palate/maxilla of patients with a complete UCLP and bilateral cleft lip and palate (BCLP).

It remains unclear whether the width of the palatal cleft is determined by a real shortage of tissue in the palatal area or whether it is related to malposition of the palatal shelves, or a combination of both factors, and how this influences maxillary arch dimensions. The purpose of this study was to compare the width and elevation of the palatal shelves between individuals unrepaired complete UCLP and BCLP with each other and a control group, and to relate these findings to the development of the maxillary arch in the permanent dentition.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion and conclusions
  7. References

Sample

The material for this study was collected through cooperation between the University of Brawijaya, Faculty of Medicine (Malang, Indonesia), Universitas Indonesia, Faculty of Dentistry (Jakarta, Indonesia), and the University Medical Centre Leiden, Department of Oral and Maxillofacial Surgery (Leiden, The Netherlands). It is part of a bigger study on unoperated CLP, with a total population of 267 adolescent and adult patients. The patients used in this study had to be in the permanent dentition with the second molars erupted in full occlusion and a chronological age of at least 13 years, as reported by the parents. A patient was considered unoperated if he had not undergone any kind of surgical or orthodontic treatment previously. Patients with submucous clefts and craniofacial anomalies were excluded. A detailed description of the population can be found in Latief et al. (2010).

Dental casts were collected of patients with unrepaired UCLP (= 68) and unrepaired BCLP (= 13). The control group consisted of 24 randomly selected non-cleft individuals from the surrounding population.

Measurements

The dental casts were digitized three-dimensionally using an industrial coordinate measuring machine (Zeiss Numerex; Carl Zeiss®, Stuttgart, Germany). With this bridge-type system accurate single-point data acquisition is possible by using a touch probe. The linear accuracy is up to 0.002 mm.

For every molar, two points were recorded: the tip of the distobuccal cusp; and the tip of the mesiobuccal cusp. In the case of abrasion of a cusp, the centre of the abraded cusp was used as the reference point. For the premolars and the canines, the tip of the buccal cusps was recorded. Between corresponding points at the right and left side, the following maxillary distances were calculated (Fig. 1):

image

Figure 1.  Occlusal view of palate showing distance measurement of maxillary width between distal cusps and mesial cusps (A) and palatal shelf width measurements (B).

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  • 171–271 distance between distal cusps of the right and left second molar;

  • 161–261 distance between distal cusp of the right and left first molar;

  • 151–251 distance between buccal cusps of the right and left second premolar;

  • 141–241 distance between buccal cusps of the right and left first premolar;

  • 131–231 distance between cusps of the right and left canine.

The upper arch ratio (%) was calculated as 131–231 distance/161–261 distance*100.

The following method was used to measure the width and elevation of the palatal shelves. Points related to teeth are described with the number of proper teeth, followed by a number indicating the position of the point on the tooth. For each maxillary first molar two points were used: the tip of the distobuccal cusp; and the point at the gingiva where the fissure between the mesial and distal palatal cusp is located (Fig. 1). Point 4 is located at the cleft margins on an imaginary line connecting point 3 at the left and right side of the maxilla for each tooth (in UCLP and BCLP only). In the control group, point 4 of the left and right side coincide in the midline of the palate. In the case of abrasion of a cusp, the centre of the abraded cusp was used as the reference point. The following linear distances (in mm) were calculated:

  • 173–174 palatal shelf width right side at the level of the second molar;

  • 273–274 palatal shelf width left side at the level of the second molar;

  • 163–164 palatal shelf width right side at the level of the first molar;

  • 263–264 palatal shelf width left side at the level of the first molar;

  • 153–154 palatal shelf width right side at the level of the second premolar;

  • 253–254 palatal shelf width left side at the level of the second premolar;

  • 143–144 palatal shelf width right side at the level of the first premolar;

  • 243–244 palatal shelf width left side at the level of the first premolar;

  • 133–134 palatal shelf width right side at the level of the canine;

  • 233–234 palatal shelf width left side at the level of the canine.

Palatal shelf elevation, which is a measure for the vertical position of the palatal shelves, was calculated as angles (in degrees):

  • 163–164/occlusal plane: palatal shelf elevation at the right side, defined as the angle between the occlusal plane and the line 163–164, representing the palatal shelf at the right side (Fig. 2);

  • 263–264/occlusal plane: palatal shelf elevation at the left side, defined as the angle between the occlusal plane and the line 263–263, representing the palatal shelf at the left side (Fig. 2).

image

Figure 2.  Side view of palate showing measurement of palatal elevation. The angle between occlusal plan (A) and palatal shelf (B) was measured.

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To determine the measurement error, 40 dental casts were digitized twice by two independent observers (BL and a technician).

Statistics

Statistical analysis was performed using spss (Statistical Package Social Sciences 16.0, SPSS Company, Chicago, IL, USA). Means and standard deviations were calculated for all variables. Occasionally reference points were missing or teeth were extracted; therefore the numbers differ per variable.

Intra- and interobserver measurement errors for transversal distances and palatal shelf widths were calculated according to Dahlberg (1940).

The t-test was used to compare the three groups. In the UCLP group the difference between the cleft and the non-cleft side palatal width and elevation was studied using the paired t-test. In the BCLP group (where there is no ‘non-cleft’ side), the difference between left and right side was tested using the paired t-test. As there was no statistically significant difference between the two sides, the mean of both shelves was taken to compare with the cleft and non-cleft side in UCLP. The level of significance was set at = 0.05.

The correlation between the shelf width and the maxillary arch width of UCLP, BCLP and the control group was studied using Pearson correlation test. Pearson correlation was also used to determine the correlation between the shelf elevation and the maxillary arch width. No alpha correction was made for multiple comparisons. The level of significance was set at = 0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion and conclusions
  7. References

Measurement error

The intra- and interobserver errors for transversal distances were small, ranging from 0.10 to 0.27 mm. The median measurement error was 0.15 mm. The measurement error for the palatal shelves ranged from 0.14 to 0.35 mm, and the measurement error for the palatal shelf angle was 0.3 °.

Maxillary arch and palatal shelf width

Table 1 shows the means and standard deviations (SD) for the width of the maxillary arch at the level of the canine, premolars and molars, and the results of inter-group comparisons. None of the transversal arch dimensions differed significantly between UCLP and BCLP, but they differed significantly from the control group for the canine and second molar distance.

Table 1.   Comparison of maxillary transversal arch dimensions (in mm) between unoperated adult UCLP, BCLP and controls.
GroupnMeanSDGroupNMeanSDDIFFP-value95% CI
  1. DIFF, difference in maxillary arch width variables between UCLP vs. control, BCLP vs. control, and UCLP vs. BCLP.

  2. Upper arch ratio = 131–231 distance/161–261 distance*100 (%).

  3. BCLP, bilateral cleft lip and palate; UCLP, unilateral cleft lip and palate.

Intercanine width (131–231)
 UCLP6330.03.7Control2436.11.9−6.10.000−7.30 to −4.51
 BCLP1028.95.9Control2436.11.9−7.20.004−11.47 to −2.99
 UCLP6330.03.7BCLP1028.95.91.140.563−3.22 to 5.39
First premolar width (141–241)
 UCLP6241.93.3Control2444.02.1−2.10.001−3.30 to −0.89
 BCLP1142.33.0Control2444.02.1−1.70.115−3.86 to 0.47
 UCLP6241.93.3BCLP1142.33.0−0.40.696−2.55 to 1.74
Second premolar width (151–251)
 UCLP5948.53.0Control2448.72.3−0.20.740−1.41 to 1.02
 BCLP1347.93.8Control2448.72.3−0.80.510−3.22 to 1.70
 UCLP5948.53.0BCLP1347.93.80.60.680−1.85 to 2.97
First molar width (161–261)
 UCLP5654.33.2Control2454.92.60.240.710−1.08 to 1.56
 BCLP1255.04.1Control2456.32.6−1.30.330−4.02 to 1.45
 UCLP5654.33.2BCLP1255.04.11.530.240−1.14 to 4.19
Second molar width (171–172)
 UCLP5360.73.5Control2458.92.83.30.000−1.76 to 4.92
 BCLP1260.24.4Control2458.82.71.40.320−1.52 to 4.37
 UCLP5360.73.5BCLP1260.24.41.90.180−1.01 to 4.84
Upper arch ratio (%)
 UCLP5653.15.5Control2464.23.2−11.10.000−13.03 to −8.65
 BCLP1051.810.4Control2464.23.2−12.40.004−19.91 to −4.93
 UCLP5653.15.5BCLP1051.810.41.360.695−6.15 to 8.87

Table 2 reports the means and SD for the width of the palatal shelves at the level of the canine, first premolar, second premolar, first molar and second molar in UCLP, BCLP and the control groups. In the UCLP group, the width of the palatal shelves on the cleft side (UCLP-C) was significantly smaller as compared with the control group. This was also found for the non-cleft side (UCLP-N), except in the canine/first premolar region. The BCLP group showed the same pattern. Furthermore, the width of the palatal shelf on the cleft side in the UCLP group (UCLP-C) did not differ significantly from the shelf width of the BCLP group.

Table 2.   Width of the palatal shelves (in mm) at the cleft and non-cleft side in unoperated UCLP subjects compared with BCLP and controls.
GroupnMeanSDGroupNMeanSDDiffP-value95% CI
  1. BCLP, bilateral cleft lip and palate; UCLP-C, unilateral cleft lip and palate cleft side; UCLP-N, unilateral cleft lip and palate non-cleft side.

Palatal shelf canine region
 UCLP-C639.12.8Control2413.91.1−4.90.000−5.72 to −4.09
 UCLP-N6815.52.8Control2413.91.11.40.0020.65 to 2.25
 BCLP1112.25.0Control2413.91.1−1.80.27−5.13 to 1.57
 UCLP-C639.12.8BCLP1112.25.0−3.10.07−6.50 to 0.25
 UCLP-N6815.52.8BCLP1112.25.03.20.059−0.14 to 6.60
Palatal shelf first premolar region
 UCLP-C6214.22.7Control2216.90.9−2.70.000−3.51 to −1.98
 UCLP-N6616.82.2Control2316.90.9−0.10.80−0.74 to −0.578
 BCLP1315.63.3Control2316.90.9−1.30.19−3.37 to −0.73
 UCLP-C6214.22.7BCLP1315.63.3−1.40.17−3.53 to 0.68
 UCLP-N6616.82.2BCLP1315.63.31.20.22−0.84 to 3.31
Palatal shelf second premolar region
 UCLP-C6618.92.3Control2221.31.5−2.40.000−3.21 to −1.51
 UCLP-N6619.82.1Control2321.31.5−1.50.001−2.29 to −0.63
 BCLP1319.12.9Control2321.31.5−2.20.02−3.99 to −0.36
 UCLP-C6618.92.3BCLP1319.12.9−0.20.80−1.97 to 1.60
 UCLP-N6619.82.1BCLP1319.12.90.70.40−1.07 to 2.49
Palatal shelf first molar region
 UCLP-C6519.42.6Control2423.61.6−4.10.000−5.04 to −3.20
 UCLP-N6820.83.0Control2423.61.6−2.70.000−3.69 to −0.1.74
 BCLP1319.33.3Control2423.61.6−4.30.001−6.26 to −2.18
 UCLP-C6519.42.6BCLP1319.33.3−0.10.88−1.94 to 2.23
 UCLP-N6820.83.0BCLP1319.33.31.50.14−0.55 to 3.65
Palatal shelf second molar region
 UCLP-C5919.73.0Control2324.91.7−5.30.000−6.31 to −4.19
 UCLP-N6221.03.3Control2324.91.7−3.30.000−5.05 to −2.84
 BCLP1219.02.8Control2324.91.7−5.90.000−7.81 to −4.01
 UCLP-C5919.73.0BCLP1219.02.80.70.48−1.26 to 2.57
 UCLP-N6221.03.3BCLP1219.02.82.00.050.02 to 3.90

Table 3 shows the means and SD for the elevation of the palatal shelves at the level of the first molar. In comparison with the control group, the angle of the palatal shelves in the UCLP subjects on the cleft and non-cleft side was larger, meaning that the palatal shelves were rotated cranially and were positioned more vertically. Also in the BCLP group, the angle of the palatal shelves was almost 10 ° greater than that of the control group. The palatal shelf elevation was not significantly different between the two cleft groups.

Table 3.   Palatal shelf elevation (in degrees) at the cleft and non-cleft side in unoperated UCLP subjects compared with BCLP and controls.
GroupnMeanSDGroupNMeanSDDIFFP-value95% CI
  1. BCLP, bilateral cleft lip and palate; UCLP-C, unilateral cleft lip and palate cleft side; UCLP-N, unilateral cleft lip and palate non-cleft side.

  2. DIFF, difference in palatal shelves elevation between two groups. The elevation of the palatal shelf in BCLP is defined as the mean of the elevation of the palatal shelves of the left and right sides.

UCLP-C6547.37.0Control2439.04.28.40.0005.96 to 10.84
UCLP-N6849.36.3Control2439.04.210.30.0008.02 to 12.61
BCLP1248.76.3Control2439.04.29.80.0005.52 to 14.08
UCLP-C6547.37.0BCLP1248.76.3−1.40.498−5.67 to 2.87
UCLP-N6849.36.3BCLP1248.76.30.50.798−3.69 to 4.73

Pearson’s correlation coefficients (Table 4) showed an association between the shelf width and the width of the maxillary arch for UCLP in the canine and first premolar area for both the cleft and non-cleft side (= 0.018 and 0.00, respectively, in the canine area; = 0.039 and 0.001, respectively, in the first premolar area). This was the same for the canine area in the BCLP group [= 0.042 and 0.042 (left and right)]. In the control group there was a significant correlation in all regions between the shelf width (left and right of the palatal midline) and the maxillary arch width, meaning wider shelves were associated with wider maxillary arches.

Table 4.   Correlation between palatal shelf width and maxillary arch width in UCLP, BCLP and control group.
GroupSide Canine1st Premolar2nd Premolar1st Molar2nd Molar
  1. BCLP, bilateral cleft lip and palate; UCLP, unilateral cleft lip and palate.

UCLPCleftCorrelation0.300.270.190.150.17
P-value0.020.040.110.240.22
n6361646152
Non-cleftCorrelation0.430.40−0.010.020.07
P-value0.000.000.940.890.59
n6966646353
BCLPLeftCorrelation0.690.350.310.270.06
P-value0.040.290.310.290.86
n911131212
RightCorrelation0.660.350.310.270.06
P-value0.040.290.310.290.86
n911131212
ControlLeftCorrelation0.650.660.560.610.56
P-value0.000.000.010.000.01
n2423232421
RightCorrelation0.650.660.560.610.56
P-value0.000.000.010.000.01
n2423232421

Table 5 reports Pearson’s correlation coefficients for elevation of the palatal shelf and maxillary arch. There was a significant negative correlation between the elevation of the shelf and the maxillary width in all regions in UCLP and in the premolar area in the control group. Thus, wider arches were associated with smaller elevation angles, meaning that the maxillary shelves are less vertically positioned. No significant correlations were found between palatal shelf elevation and arch width in BCLP individuals.

Table 5.   Correlation between palatal shelf elevation and maxillary arch width in UCLP, BCLP and control group.
GroupSide Canine1st Premolar2nd Premolar1st Molar2nd Molar
  1. BCLP, bilateral cleft lip and palate; UCLP, unilateral cleft lip and palate.

UCLPCleftCorrelation−0.26−0.41−0.51−0.44−0.28
P-value0.040.000.000.000.05
n6564626149
Non-cleftCorrelation−0.25−0.48−0.53−0.37−0.31
P-value0.040.000.000.000.03
n6867646352
BCLPLeftCorrelation−0.24−0.11−0.29−0.41−0.20
P-value0.510.770.370.190.55
n1010121211
RightCorrelation−0.24−0.11−0.29−0.41−0.20
P-value0.510.770.370.190.55
n1010121211
ControlLeftCorrelation−0.28−0.46−0.49−0.36−0.22
P-value0.190.020.020.080.32
n2424242422
RightCorrelation−0.28−0.46−0.49−0.36−0.22
P-value0.190.020.020.080.32
n2424242422

Discussion and conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion and conclusions
  7. References

Age is not always exactly known in remote areas of Indonesia. Therefore we used dental stage in combination with chronological age, the lowest age being 13 years. There are hardly any longitudinal studies on transverse maxillary growth, and not any from the Indonesian population. The Iowa Facial Growth Study, a longitudinal study from 7.6 to 26.4 years, has shown that maxillary transverse width changed less than 1 mm after 12.9 years old (Hesby et al. 2006). In our study population there was only one individual out of 105 (a female) belonging to the UCLP group who was 13 years old, all other individuals in the study sample were older. We decided not to exclude this individual as it would have virtually no effect on the outcome of the study.

In the current study, the sample size of the UCLP group was large, but the BCLP group was small. Despite this difference in sample size, our results do allow some preliminary conclusions on the investigated variables. In UCLP and BCLP unoperated individuals, the palatal shelf width was generally smaller in comparison to the non-cleft control group. This was also found in the study of Diah et al. (2007). This finding suggests a deficiency in the amount of available tissue, not only at the cleft side but also in UCLP at the supposedly normally developed non-cleft side.

This is in agreement with Lo et al. (2003) who performed a three-dimensional surface analysis of the palatal shelves on dental casts of 3-month-old babies before any operation. The UCLP and BCLP groups had a significantly smaller palatal surface area than the unilateral cleft lip without cleft palate (UCL) and isolated cleft palate (CP) groups. There was no significant difference between the UCLP and BCLP groups. Their findings also suggest that, compared with patients with UCL and CP, there is an intrinsic tissue deficiency of the palate/maxilla of patients with UCLP and BCLP. Ye et al. (in press) also demonstrated this; they found a difference in palatal surface area between operated and unoperated patients with UCLP compared with normal controls. The findings in this study as well as the study of Diah et al. (2007), in which additionally to our measurements they also measured the surface area, show that the intrinsic differences already found at birth (Ye et al. in press) continue throughout life when no intervention is done.

Regarding the transverse maxillary arch dimensions, studies on newborns have shown that patients with UCLP and BCLP have wider separated palatal shelves than newborns without clefts (Will, 2000). In a review of growth in untreated patients, she confirmed that the skeletal, and thus dental, width of the cleft maxilla is not inherently decreased at birth but is rather increased (Will, 2000). In our sample the UCLP individuals still had wider maxillas at the level of the second molars. We could not confirm this in the BCLP group, maybe due to the small sample size in BCLP. In fact, transverse developmental disturbances were rather limited to the vicinity of the cleft. We can only speculate on the reasons, but the development to normal maxillary dimensions could be brought about by muscle function over the patient’s lifetime.

In the present study, palatal shelves in the UCLP and BCLP groups were positioned more cranially compared with controls. The same was found for the cleft side palatal segment in UCLP by Derijcke et al. (1994) and Lekkas et al. (1997), who compared palatal morphology in patients with UCLA and UCLP. Additionally, Mishima et al. (2001) three-dimensionally examined the palatal configuration in incomplete and complete UCLP at birth, and found that the palate in complete UCLP showed more curvature in comparison with the palate of incomplete UCLP. We also found a correlation between palatal shelf elevation and maxillary arch width in patients with UCLP. If the maxilla was wider, the palatal shelf was positioned less vertical. We did not find this in the BCLP group. The palatal shelves start developing at the end of week six in utero and are marked by vertical growth. At the end of week eight, the palatal shelves start to grow horizontally and fuse rapidly (Yoon et al. 2000). Looking at the two malformations, UCLP vs. BCLP, one could speculate that because the palatal shelf in subjects with UCLP is connected to the nasal septum, the shelf flattens more during vertical growth at the non-cleft side when a wider arch form is present. In the BCLP group, no correlation between arch width and palatal shelf elevation was found. As the palatal shelves in the BCLP group are also positioned more cranially, interposition of the tongue could be responsible for this upward rotation as well the maintenance of upward rotation with a wider maxillary arch.

The findings of this study may have some clinical implications. Smaller palatal shelf width and larger elevation of the shelves result in a wider cleft. The surgeon trying to bridge the gap, especially when using the Langenbeck technique, creates a great empty space between the elevated palatal mucosa and the denudated bone of the palatal shelves. The scar tissue developing between these two structures contracts, potentially resulting in transverse compression of the maxilla and malpositioning of the teeth. This finding is frequently seen in the operated cleft lip, alveolus and palate patients. Therefore, there is a need to design surgical techniques that take into account this intrinsic deficiency, which might result in better long-term dentomaxillary development.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion and conclusions
  7. References
  • Bishara SE (1973) Cephalometric evaluation of facial growth in operated and non-operated individuals with isolated cleft of the palate. Cleft Palate J 3, 239246.
  • Bishara SE, Krause CJ, Olin WH, et al. (1976) Facial and dental relationship of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J 13, 238252.
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