Secondary cleft surgery

160 Pages·2002·7.458 MB·English

by  Orrett E. Ogle

OralMaxillofacialSurgClinNAm14(2002)ix
Preface
Secondary cleft surgery
OrrettE.Ogle,DDS
GuestEditor
This issue of Oral and Maxillofacial Surgery traction osteogenesis to manage the cleft patient is
Clinics of North America is devoted to secondary included andshows great promise.
cleft surgery. Not many nonacademic oral and max- Two disciplines that are essential to the total
illofacial surgeons are currently involved in primary rehabilitation of the cleft patient are speech therapy
cleft repair, but secondary cleft surgery is an area in andorthodontics.Theeffectofsurgicalprocedureson
which we play an important role. Rehabilitation of speech is discussed in detail, and the role of ortho-
the child with a cleft is truly a team effort in which donticsisincludedsoastogivethesurgeonabetter
expertiseinonedisciplinecomplementstheotherand understanding of orthodontictreatment. Thesurgeon
no particular specialty alone can achieve all of the also must understand the effects of surgery on the
desired goals of the child’s rehabilitation. Each spe- growth and development of the face, jaws, and
cialty brings something unique to the table, and as dentition. This view is presented as a comparison to
such, we have included articles by plastic surgeons, cleft palate patients whoneverhadsurgery.
oral and maxillofacial surgeons, speech therapists, The contributing authors are all experienced
and orthodontists. We also have included well- with cleft patients and have provided effective
respected authors from outside the United States solutions to the varied presentations that we may
whooffer awider perspective. encounter in secondary cleft surgery. I wish to
Primary cleft surgery calls on every aspect of thank all of the authors for agreeing to participate
surgical skill and aesthetic sense. The goal of the in this project, which was so dear to me, and for
primaryrepairistoachieveasnormalanappearance providing the quality articles included in this issue.
as possible with satisfactory function of speech and I sincerely hope that readers will find this issue
mastication. The desired goals are not always useful and enjoyable.
achieved, and unplanned secondary procedures are
oftenrequired.Someoftheseproceduresarecovered Orrett E. Ogle, DDS
inarticlesonscarrevisionofthecleftlip,surgeryto Department of Dentistry
correct the short lip, repair of palatal fistulas, and OralandMaxillofacial Surgery
velopharyngealincompetence.Notallsecondarycleft Woodhull Medical andMentalHealth Center
surgery is unplanned, however, but is staged. These 760Broadway,Room2B-320
staged surgeries include alveolar bone grafting and Brooklyn, NY11206,USA
orthognathic surgery. The recent innovation of dis- E-mailaddress:[email protected]
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PII:S1042-3699(02)00051-1
OralMaxillofacialSurgClinNAm14(2002)411–424
Facial and dental relationships in individuals with
cleft lip and/or palate
Samir E. Bishara, BDS, DDS, MS
DepartmentofOrthodontics,CollegeofDentistry,UniversityofIowa,219DentalScienceS,IowaCity,IA52242,USA
Managementofindividualswithcleftsofthelipor obtainedessentiallythesametypeoftreatment
palateorbothisacomplexprocedure.Thecomplex- fromthesamegroupofspecialists.
ity is a result of the variation among different cleft
types and individual variation within the same cleft The purpose of this article is to describe and
type. All this is superimposed onvarious techniques explainthefacialanddentalrelationshipsinindivid-
by which different craniofacial centers or individual uals with different cleft types with and without a
specialists treat their patients surgically, orthodontic- surgical repair. An attempt is made to outline the
ally,andotherwise. different variables that must be considered in the
Many investigators [1–20] have concluded that study of the craniofacial growthof the cleft face.
the dentofacial relationships of individuals with
repaired clefts differ from those of persons with-
out clefts. Many factors can interplay to cause
Facialcharacteristicsofindividualswithdifferent
such differences:
types ofunrepaired andrepairedclefts
1.Changesinthefacialstructurescouldbepartof
Intheattempttobetterunderstandfacialgrowthin
a syndrome that includes other manifestations,
cleft lip and palate patients, it may be helpful to
suchas cranial deformities.
answer the following questions systematically:
2.Changesinthefacialstructurescouldbepartof
a response to the mechanical presence of a
1.Does the unoperated cleft individual have
defect (ie, when there is a tissue deficiency,
the same facial growth potential as the non-
variousstructuralcompensationsareneededto
cleft individual?
improve function).
2.Do all unoperated cleft types have the same
3.Changes in the facial structures could be the
growthpotential?
result of the different management procedures,
3.What effects does cleft management have on
suchas surgeryand orthodontics.
facial anddental growth?
4.Individualswithcleftspossesstheirowngenetic
andacquiredpotentialtodevelopintoaClassI,
The logic behind these questions is obvious, be-
II, or III dental or skeletal patterns. This fact
causeitisimportanttodeterminehowan‘‘unrepaired
explainswhythedentofacialrelationshipintwo
cleft face’’ looks before attempting to determine the
individualswithsimilarcleftscanlooksignifi-
effectof management.
cantlydifferentfromeachotherdespitehaving
The following discussion encompasses the fol-
lowing descriptions: (1) the cephalometric relation-
ships of the dentofacial structures (ie, maxilla,
mandible, maxilla-mandible, and dentition, and (2)
the dental arch relationships of the anterior and
E-mailaddress:[email protected] posterior segments.
1042-3699/02/$ – seefrontmatterD2002,ElsevierScience(USA).Allrightsreserved.
PII:S1042-3699(02)00043-2
412 S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424
Background then why did the maxilla and mandible become
relatively retruded in the obturated group? One also
Numerous studies consistently demonstrated that mayinterpretthesefindingstomeanthattheskeletal
thefacialanddentalrelationshipsofindividualswith changes observed are, at least in part, related to the
repaired clefts differ from those of noncleft individ- presence of the cleft itself rather than the effect of
uals. Most of these differences have, until recently, palatalrepair.
been blamed on the lip and palatal surgery and on These observations are specifically related to the
other rehabilitative procedures. skeletal facial structures. Palatal surgery has definite
Findingsonindividualswithisolatedcleftsofthe unfavorable effects on the maxillary dental arch
palate precipitated a reevaluation of the understand- dimensions and on the occlusion, because palatal
ingoftherelationshipbetweensurgicalmanagement, surgerycausesconstrictionofthemaxillaryarchand
clefting, andfacial growth. Howdid thishappen? anincreaseintheincidenceofanteriorandposterior
One of the initial questions raised was how do cross-bites[8].
individuals with isolated clefts of the palate (CPO) Animal research helped provide important infor-
differ from normals? mation.Cheiricietal,in1973,createdpalatalcleftsin
In an attempt to answer this question, 20 female otherwise normal Rhesus monkeys [7]. They found
subjects with CPO were compared to 25 noncleft thattheinducedpalatalcleftscausedthemaxillaand
female subjects [2]. Female subjects were chosen mandible to become retrusive. From these findings
because this type of cleft occurs more frequently in one can assume that the changes in facial relation-
the female gender. To minimize the effect of growth shipsintheunrepairedindividualsarearesponsetoa
onthe interpretation of the results, it was decided to tissuedeficiency(ie,biomechanicalcompensationsto
include only individuals who were age 16 years or the presence of thepalatal cleft).
older. The comparisons between the cleft and non- One always should be cautious as to interpreting
cleft groups indicated the presence of significant the findings from animal experimentation and their
differencesinthemaxillaryandmandibularrelation- direct application to humans. However, the cumula-
ships between the two groups. Specifically, the tive findings from human and animal observations
maxilla and mandible were relatively retruded as partly explain the differences between individuals
compared to the normal subjects; however, the with and without palatal clefts. More importantly, it
maxilla and mandible were in an acceptable rela- points to the need for a reexamination of the under-
tionship to each other as indicated by the positive standing of the unoperated cleft face. Without such
maxillary-mandibular apical base relationship knowledgeitbecomesdifficulttoinferthatthefacial
(ANB) angle. Similar results were reported earlier relationship and the occlusal discrepancies in the
by Dahl [8]. repaired cleft face are exclusively the result of sur-
The cause of these differences between the cleft gical management.
group and normal group traditionally has been
attributed to palatal surgery. The next question
was: Why should palatal surgery cause mandibular
retrusion? The author examined a sample of indi- Dentofacial characteristics of differenttypes of
viduals with isolated clefts of the palate, but some cleft faces beforeandaftersurgical repair
ofthesesubjectswereobturated,whereasotherswere
operated [2]. The two groups were then compared For this discussion to have a perspective, the
cephalometrically. Surprisingly, there were no sig- effects of the presence of the cleft and the effect of
nificant differences between the two groups in their surgery are presented for the three most commonly
cephalometric skeletal facial relationship. Both occurring cleft types, starting with the less severe
groups were found to have a similarly retruded clefts, inthe following order:
maxilla and mandible, a steep mandibular plan,
and upright mandibular incisors. Individuals with unilateral cleft lipandalveolus
Data from earlier studies by Hagerty and Hill in Individuals with cleft palate only
1963onPuertoRicans[11]andDahlin1970onthe Individuals with complete unilateral cleft lip
Danish cleft population [8] confirmed these results. andpalate
Whatisthesignificanceofallthesefindings?Doesit
mean that palatal surgery as performed on these Itisimportanttorememberthatwithineachcleft
subjects had no effects on the anteroposterior and type, various degrees of malrelationship are ex-
vertical growth of the facial skeleton? If this is true, pressed. In each individual, clefting of the lip or
S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424 413
Table1
Effects of surgical management on cephalometric dentofacial relationships in individuals with unilateral cleft of the lip
andalveolus
UnrepairedUCLA OperatedUCLA
Cephalometricfindings vs.normals[3,5] vs.normals[8] Effectofsurgery
Maxilla Tendencyformaxillary Nodifference Theinfluenceoflipsurgery
protrusioninUCLA inrelationship causedrecontouring
Greatermaxillary Smallermaxillary ofthepremaxilla
depthinUCLA depthinUCLA
Botharebelievedto
betheresultofthe
forwardrotation
ofthenon-cleftsegment
Mandible Nodifferenceinsize Nodifferenceinsize Noinfluence
andrelationship andrelationship
Maxilla-mandible LargerANBandangle Nodifference Theinfluenceofthelipsurgery
ofconvexityinUCLA inrelationship onthemaxillaimproved
becauseofthe maxillary-mandibularrelationship
maxillaryprotrusion
Dentition
Upperincisors Nodifference Inclinedlingually Lipsurgerycausedthe
inUCLA incisorstotiplingually
Lowerincisors InclinedlabiallyinUCLA Inclinedlingually Noinfluence
inUCLA
Abbreviations:ANB,Maxillary-mandibularapicalbaserelationship;UCLA,unilateralcleftofthelipandalveolus.
palate or both is superimposed on the genetic and mandibular relationship, however, does not seem to
epigenetic potential of the particular individual, be influenced significantly by the presence of an
whichisafindingthathasbeenobservedrepeatedly alveolar cleft of the primary palate (Fig.1).
in normal populations [21–28]. Within each cleft Dental relationship: When the maxillary dental
group there is a large range of variation, and the archisviewedocclusally(Fig.2A),theanteriorpart
following descriptions serve as general characteriza- of thenoncleftsegment hasatendencyto berotated
tionsfor eachcleft type. forward, hence the increased overjet, as a result of
incisor protrusion. The cleft segment has a tendency
to rotate slightly medially, however, so there is a
Personswith unilateral cleft lip andalveolus tendency for the canines to be edge to edge and
sometimes in cross-bite. When viewed labially
Unrepairedunilateral cleftlip andalveolus (Fig. 2B), the teeth on either side of the cleft have
a tendency to roll superiorly, which results in these
Skeletalrelationship[3,5]:Thereisatendencyfor teeth being in infraocclusion with a localized open-
maxillaryprotrusionintheunrepairedcleftsascom- bite tendency.In summary,theeffectsofthe cleftof
pared to the noncleft subjects (Tables 1, 2). The the lip and alveolus are limited to that part of the
Table2
Effectsofsurgicalmanagementondentalrelationshipsinindividualswithunilateralcleftofthelipandalveolus
Dentalfindings UnrepairedUCLA OperatedUCLA(%) Effectofsurgery
Incisorinversion 12.5% 18.5 Increasedincidenceofanteriorcross-bite
Mandibularoverjet None 5.6
Posteriorcross-bite
Uni- 12.5% 23.6 Increasedincidenceofposteriorcross-bite
Bi- None 14.5
Abbreviation:UCLA,unilateralcleftofthelipandalveolus.
414 S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424
incisor inclination and an increased incidence of
anterior andposterior cross-bites (Tables 1,2).
Surgicalandorthodontic implications
The description of the unoperated face provides
an explanation of some of the differences in the
dentofacial relationships between individuals with
repaired clefts of the lip and alveolus and normal
individuals [3,5,8] As an example, in individuals
withunilateralcleftlipandalveolus,thepresenceof
the intact secondary palate minimizes the effect of
the lip surgery on the maxillary skeletal base.
Fig.1.Skeletalrelationshipsofthemaxillaandmandiblein
Dahl [8] found that at the end of the growth
individualswithunrepairedcleftlipandalveolus.
period, the maxillary-mandibular relationships in
operated individuals with unilateral cleft lip and
alveolus were comparable to those in noncleft indi-
dentofacial complex that surrounds the cleft area viduals. Lip surgery can improve substantially the
(Fig.3). increased overjet caused by the rotation of the
noncleft segment and also improve the maxillary-
Effects oflip repaironthe skeletal structures in mandibular skeletal anteroposterior relationship. On
unilateralcleft lipandalveolus [8] the other hand, lip surgery can cause or accentuate
dental discrepancies, such as cross-bites [8].
Maxilla: Lip repair has a molding effect on the Most of these dental discrepancies in individuals
anterior maxilla that results in a reduction of the with unilateral cleft lip and alveolus can be treated
maxillaryprotrusion to amorenormal relationship. successfully orthodontically. The stability of the
Mandible: No significant changes in either the orthodontic correction is influenced to a degree by
mandibular relationship or dimension occurred as a some of the dental tendencies that have been
resultof the liprepair. observed in the ‘‘unrepaired’’ cleft face (eg, teeth
Maxillary-mandibularrelationship:Theimprove- in infraocclusion) (Fig. 2A–D). A prolonged period
mentinthisrelationshipaftersurgerywasreflectedas ofretentionorevenpermanentretentionforseverely
areductionintherelativelylargeANBangle.Thisis affectedteethoneithersideof thecleftmay haveto
the result of the decrease in the protrusion of the be considered. In summary, lip surgery by itself has
anterior part of the maxilla after lip repair. In sum- little detrimental effect on skeletal facial growth; it
mary,asaresultoflipsurgery,theskeletalstructures actually might have a beneficial effect on the pro-
of individuals with unilateral cleft lip and alveolus truding noncleft segment. On the other hand, lip
have been restored to a relationship that for all repair results in an increased incidence of anterior
practical purposes can be described as similar to and posterior cross-bites.
noncleft individuals(Tables 1,2).
Persons with isolated clefts of thepalate
Effects oflip repaironthe dental structures
Unrepairedisolated cleftsof the palate[2,8]
Incisor inclination: In the repaired unilateral cleft
lip and alveolus, the maxillary incisors were rel- Skeletal relationships: The presence of a palatal
atively protrusive, and lip repair caused maxillary cleftseemstobeassociatedwiththeretrusionofthe
andmandibularincisorstobecomemoreupright.The maxilla and mandible in relation to the cranial base,
uprighting tendency was greater for the maxillary buttheyremainwellrelatedtoeachother(Fig.4).The
teeth and resulted in a decrease in the overjet and mandibularplaneisrotatedbackwardanddownward.
anincrease in theincidence ofanterior cross-bite. Dentalrelationships:Themandibularincisorsare
Posterior transverse relationship: There was an inclined lingually.
increase in the incidence of unilateral and bilateral Dental arches: The presence of an unrepaired
posterior cross-bites as a result of lip repair. In palatalcleftdoesnotseemtoinfluencethemaxillary
summary, cleft lip repair results in a decrease in dentition adversely (Fig. 5).
S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424 415
Fig. 2. (A) Occlusal view of the dental arches in an individual with cleft lip and alveolus. (B) Frontal view of the occlusal
models,whichshowsthetendencyoftheteethtorollsuperiorlyoneachsideofthecleft.Lateralviewofthemodelsonthe
noncleft(C)andcleft(D)sides.
Effectsofpalatalsurgeryontheskeletalstructuresof (Tables3,4).Bycomparingrepairedwithunrepaired
isolatedcleftsof the palate (obturated) individuals with isolated clefts of the
palate, one can assume that existing differences, for
Individuals with isolated clefts of the palate pre- the most part, could be attributed to the surgical
sentanattractivemodeltostudytheexclusiveeffects management of the palate.
ofpalatesurgeryonfacialanddentalgrowthbecause Maxilla:Nosignificantchangesintheanteropos-
the influence of the presence of a lip and alveolar terior relationship of the maxilla were present be-
cleft and the effect of lip repair are all eliminated tween the operated and obturated groups. Posterior
416 S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424
Fig. 5. Maxillary dentition of an individual with an
unrepairedcleftpalateonly.
Maxillary-mandibular relationship: There was a
reduced ANB angle in the group with operated
isolated clefts of the palate group. In summary, one
canconcludethatpalaterepairhasonlyasubtleeffect
on the skeletal relationship of the maxilla and man-
dible because most cases in the group with repaired
isolatedcleftsofthepalatemaintainedapositivebut
smaller than normal ANB angle. On the other hand,
the effect of the combined reduction of the ANB
angle with the mandibular forward rotation that
Fig.3.Facialviewofanindividualwithanunrepairedcleft
occurs after palatal repair should be considered as
ofthelipandalveolus.
disadvantageous. This is because the combined ef-
fects of these changes might predispose some indi-
maxillary height was shorter in the operated group,
viduals to have a concave facial profile and an
which indicates that palatal surgery has affected the
increase inthe incidenceof anterior cross-bites.
posterior descentof thepalate.
Mandible: No differences were present in the
Effects of palatal repaironthe dental structures
mandibular skeletal relationship or dimensions,
except that the mandibular plane was steeper in the
Incisorinclinations:Palatalrepaircausedaslight
groupwith obturated isolatedclefts of the palate.
decrease in the angulation of the upper incisors and
anincrease inthe incidenceof anterior cross-bite.
Posterior transverse relationship: Comparisons
between the operated and obturated cleft groups
indicated that there was a marked increase in unilat-
eralandbilateralposteriorcross-bitesintheoperated
group [8].
Surgicalconsiderations
Ingeneral,palatoplastyinindividualswithisolated
cleftsofthepalatedoesnotresultingrossanteropos-
teriorskeletalmaxillary-mandibulardiscrepancies.In
persons with an inherent tendency for maxillary
retrusion, however, the palatoplasty possibly could
accentuate the maxillary retrusion, leading to an
Fig.4.Skeletalrelationshipsofthemaxillaandmandiblein unfavorable maxillary-mandibular relationship. On
individualwithunrepairedcleftpalateonly. theotherhand,palatalsurgeryhasamorepronounced
S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424 417
Table3
Effectsofsurgicalmanagementonthecephalometricdentofacialrelationshipsinindividualswithcleftofthepalateonly[2,8]
OperatedCPO UnoperatedCPO
Cephalometricfindings vs.normals vs.operatedCPO Effectofsurgery
Maxilla Maxillaryretrusion Maxillaryrelationship Littleeffectonthe
intheCPO similar anteroposteriorskeletal
Maxillarydepthshorter Alldimensionsarethe relationshipordimensions
andmaxillaryapicalbase sameexceptforadecreased forthemaxilla
widthnarrower—posterior posteriorfaceheightinthe
faceheightshorter operatedgroup(i.e,possible
maxillarybackwardrotation)
Mandible Mandibularretrusion Mandibularrelationshipsimilar Palatoplastymaydecreasethe
intheCPO SteepnessofMPmore tendencyforasteepMPand
Steepmandibularplane intheunoperated increasetheforwardrotation
inCPO
Maxilla-mandible TheANBangleissmaller ReducedANBangleasa Causesreductioninthe
butnotsignificantly resultofthesubtlechangesin ANBangle
differentfromnormals themaxillaandmandible,
buttheANBangleis
stillpositive
Dentition
Upperincisors MoreuprightinCPO Similarinclination Nosignificanteffectson
incisorinclination
Lowerincisors MoreuprightinCPO Similarinclination
Abbreviations:ANB,Maxillary-mandibularapicalbaserelationship;CPO,cleftofthepalateonly;MP,Mandibularplane.
effectonthemaxillarydentalarch,whichleadstothe Persons with unilateral cleft lip andpalate
increased incidence of posterior and anterior cross-
bitesinthesurgicallytreatedsubjects. Unrepairedunilateralcleft lipandpalate
In summary, palatal repair in individuals with
isolated clefts of the palate has a more significant Individuals with unilateral cleft lip and palate
effect on the dentition compared to the skeletal express the combined effects of (1) the presence of
structures.Thesizeandlocationofthesurgicalwound acleftofthelipandalveolus,inwhichthepremaxilla
relative to the anterior and posterior teeth have an on the noncleft side is rotated forward [3,5] and (2)
influence on the severity of the dental changes. The the presence of a cleft palate, which causes the
largerandcloserthecontractingwoundistotheteeth, maxilla and mandible to be relatively retrusive
themoreadversearethedentalchanges. (Tables 5,6) [2,7,8].
Table4
Effectsofsurgicalmanagementondentalrelationshipsinindividualswithcleftofthepalateonly
Dentalfindings UnoperatedCPO(%) OperatedCPO(%) Effectofsurgery
Incisorrelationship
Normal 90.9 70 Increaseinanteriorcross-bite
Incisorinversion 0 10
Mandibularoverjet 0 15
Extrememaxillaryoverjet 9.1 5
Transverseocclusion
Normal 80 51.3 Dramaticincreaseinposteriorcross-bite
Unilateralcross-bite 10 20.5
Bilateralcross-bite 10 28.2
Abbreviation:CPO,cleftofthepalateonly.
4
1
8
Table5
S
Effectsofsurgicalmanagementonthecephalometricdentofacialrelationshipsinindividualswithunilateralcleftofthelipandpalate[3,5,8] .E
.
B
UnoperatedUCLP UCLPwithoperated UCLPwithoperatedlipandpalate is
h
Cephalometricfindings vs.normal liponlyvs.normals vs.UCLPwithoperatedliponly Effectoflip/palatalsurgery a
r
a
Maxilla Nodifferenceinrelationship Maxillaryretrusion Greatermaxillaryretrusionthanwith Thelipsurgerycausesthemoldingof /
O
anddimension lipsurgeryonly theanteriorpartofthemaxilla r
a
Maxillaryapicalbasewidthissmaller andmakesthemaxillaslightlyretruded l
M
inthegroupwithoperatedpalate Lipandpalatalsurgeriescausethe a
x
maxillatobefurtherretruded illo
Mandible Mandibularretrusioninthe Similarrelationship Similarrelationship,buttheMPisless Palatalsurgerymaydecreasethe fa
c
UCLPandsteepmandibularplane steepinthegroupwithoperatedpalate steepnessoftheMP ia
l
Maxilla-mandible Nodifferenceinrelationship Nodifferenceinrelationship NegativeANBrelationship LipsurgerydecreasestheANBangle, Su
butthepalatalsurgeryfurtherdecreases rg
C
theANBangletoanegativevalue lin
Dentition N
Upperincisors Nodifferenceininclination Moreuprightthannormals Nodifference Lipsurgerycausestheupperincisors A
m
toupright
1
Lowerincisors Moreuprightthanthenormals Moreuprightthannormals Nodifference Lowerincisorsareuprightinthe 4
(2
unoperatedandoperatedUCLPwhen 0
0
comparedtonormals 2)
4
Abbreviations:ANB,Maxillary-mandibularapicalbaserelationship;MP,Mandibularplane;UCLP,unilateralcleftofthelipandpalate. 11
–
4
2
4
S.E.Bishara/OralMaxillofacialSurgClinNAm14(2002)411–424 419
Table6
Effectsofsurgicalmanagementondentalrelationshipsinindividualswithunilateralcleftofthelipandpalate[8]
Unoperated CLPwithoperatedlip CLPwithoperatedlip
Dentalfindings CLP(%) only(%) andpalate(%) Effectofsurgery
Incisorrelationship
Normal 83 64.3 30.5 Lipsurgeryincreasesthe
inversionofupperincisors
Inversionofincisors 17 35.7 32.2 Lipandpalatalsurgeriesalso
createanincreasedincidence
ofmandibularoverjet
Mandibularoverjet 0 0 37.3
Transverseocclusion
Normal 46 52.9 9 Mostoftheunilateral
cross-bitesareonthecleftside.
Unilateralcross-bite 27 41.2 50 Lipsurgeryincreasesthe
incidenceofcross-biteslightly.
Bilateralcross-bite 9 5.9 41 Lipandpalatalsurgeryincreases
incidencegreatly.
Buccalcross-bite 18 0 0 Buccalcross-biteisonlypresent
intheunoperatedgroup.
Abbreviations:CLP,cleftlipandpalate;UCLP,unilateralcleftofthelipandpalate.
Skeletal relationships: The result of these oppos- creased incidence of cross-bite [1,3,5]. On the non-
ing influences on the unoperated maxilla is that it cleftside,thepremaxillarysegmenthasatendencyto
maintainsa‘‘normal’’relationshiptothecranialbase. rotate forward and laterally, which increases the
The mandible, on the other hand, is rotated back- incidence of Brophy’s syndrome in the premolar
ward as a result of the presence of the palatal cleft area (ie, maxillary premolars with buccal overjet)
(Fig.6). (Fig. 7C)[5].
Dental relationships: Occlusal view: In the max- Lateralview:Thereisatendencytowardinfraoc-
illaryarch,therelationshipofthecleftsegmenttothe clusion of the teeth on either side of the cleft defect
noncleft segment varies from normal to different (Fig. 7D), which is similar to what is seen in
degreesofmedialcollapse,particularlyinthecanine individuals with unrepaired unilateral cleft lip and
area (Fig. 7A,B). This relationship causes an in- alveolus [3,5].
Effects of surgeryin unilateralcleft lipandpalate
Itisoftenassumedthatallthedisturbancesinthe
facial growth of individuals with repaired clefts of
the lip or palate or both are the result of the effects
of lip and palatal surgeries. But is the surgery the
only explanation of the patient clinical picture, or is
itthecombinedeffectofsurgeryandthepresenceof
the cleft?
Earlier in this article, the effect of lip surgery on
individuals with unilateral cleft lip and alveolus and
the effects of palatal surgery on individuals with
isolated clefts of the palate were outlined. It is
important to remember that in each of these two
Fig.6.Skeletalrelationshipsofthemaxillaandmandiblein groups either the primary or secondary palates were
individuals with unrepaired unilateral complete cleft lip intact. As aresult, in these two cleft types there is a
andpalate. partialanatomicsupportforthedentitionandalveolar