The aim of the mention article was to compare vertical maxillofacial growth in patients born with unilateral cleft lip and palate (UCLP) who were treated using two different surgical protocols.
Cleft lip and palate (CLP) is one of the most common congenital anomalies. Treatment protocols for management of children with CLP differ markedly between cleft teams (Mossey et al., 2009). Between 1965 and 1974, the protocol used by the cleft team in Gothenburg, Sweden, included hard palate closure using a cranially based vomer flap followed by a Wardill-Kilner (W-K) push-back palatoplasty. This technique led to poor midfacial growth and occlusion (Friede and Johanson, 1977). Based on follow-up studies, the protocol was changed in 1975 by introducing a delayed hard palate closure technique (DHPC). This method included closure of the soft palate with a posteriorly based vomer flap in the first year of life. Closure of the hard palate was delayed until the stage of mixed dentition. This DHPC technique showed significantly better long-term midfacial growth and occlusion (Friede et al., 1980, 2012; Friede, 1998), with favorable speech development (Lohmander-Agerskov, 1998; Lohmander et al., 2012).
Graber (1949) pioneered the research on factors influencing maxillary development in CLP patients and stated that cleft surgery had a detrimental effect on maxillary growth (Graber, 1949). Restricted maxillary growth has been a constant finding in studies evaluating CLP patients treated according to different surgical protocols (Ross, 1987; Semb and Shaw, 1998; Khanna et al., 2012). Most previous work has been focused on craniofacial growth in the sagittal and transverse dimensions (Mars et al., 1992; Molsted et al., 1992; Lisson et al., 1999).
The vertical maxillary growth restriction has been shown to be a common finding in operated cleft patients, and it has also been shown to vary between different surgical techniques and their timing (Ross, 1987). Moreover, the growth restriction has been found to differ between anterior or posterior maxillary dimensions and to change the maxillary inclination angle (Swennen et al., 2002). Reduced anterior vertical maxillary growth can be observed clinically as reduced overbite (Ross, 1987; Lisson et al., 2005), and reduced posterior vertical maxillary growth has been suggested to affect speech (Stellzig-Eisenhauer, 2001).
The effect of surgery on vertical maxillary growth in patients with CLP is less well understood, and further investigation of the effect of different surgical protocols on these dimensions is still needed. The aim of the present study was to compare how vertical maxillary growth is affected by W-K with cranially based vomer flap and by the Gothenburg DHPC with posteriorly based vomer flap.
The study was conducted on lateral cephalometric radiographs taken at 10 years of age from 92 consecutive Caucasian patients born with unilateral cleft lip and palate (UCLP). The patients underwent surgical treatment at the Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
Exclusion criteria were: secondary palatal surgical procedure, syndromic clefts, craniofacial or systemic anomalies, and presence of Simonart's band of more than 0.5 mm. Fistula closure was not regarded as an exclusion criterion.
The patients were divided into two groups according to the surgical protocol used.
The W-K group consisted of 46 consecutive patients born between 1965 and 1974
This study revealed significantly higher values for anterior upper facial height, anterior maxillary height, and overbite in the Gothenburg DHPC group than in the W-K group However, while the values for anterior upper facial height seemed to approach noncleft reference values in the DHPC group more than in the W-K group, the maxillary inclination showed the opposite tendency (Thilander et al., 2005).
The findings of a more normal anterior upper facial height, anterior maxillary height, and overbite in the DHPC than in the W-K group are in accordance with previous studies using the DHPC protocol, which showed favorable maxillary growth for all dimensions investigated compared to the W-K protocol (Friede and Johanson, 1977; Friede et al., 1980, 2012; Bakri et al., 2012).
The normal growth of the maxillary complex has been extensively studied; regarding vertical dimension, the maxilla is relocated downward through appositional growth in the hard palate and the alveolar process. The bony surfaces of the maxilla are selectively resorptive or depository to maintain the general shape of the midface during growth (Bjork and Skieller, 1974). Normal midfacial growth also involves displacement of the maxilla forward and downward in relation to the vomer. Through studies of CLP patients, the displacement has been documented to occur in the vomeropremaxillary suture and mainly during the first year of life (Friede, 1977,1978).
The vertical dimension of the maxilla is close to normal in unoperated cleft patients, indicating that surgery is the factor mainly responsible for growth restriction (Lambrecht et al., 2000). Thus, in the W-K technique, extensively denuded palatal bone results in scar tissue that negatively affects the maxillary growth in all dimensions (Ross, 1970; Ishikawa et al., 1998). The cranially based vomer flap in this technique is suggested to result in bone formation across the cleft, in addition to disturbing the vomeropremaxillary suture, resulting in increased restriction of maxillary growth (Prydso et al., 1974; Friede and Johanson, 1977; Friede and Lilja, 1994). However, the DHPC technique in the present study included early soft palate closure, and the remaining cleft in the hard palate has been shown to narrow markedly until the hard palate closure, instead reducing cicatrization from hard palate repair (Owman-Moll et al., 1998; Friede and Enemark, 2001). Moreover, whatever technique is used, operating on the cleft palate at later age has also been shown to reduce the restriction of the maxillary growth (Bardach et al., 1984; Xu et al., 2012). The DHPC techniques showed cephalometric values that were lower than in noncleft individuals, indicating that restricted vertical growth still occurs (Thilander et al., 2005). This is in agreement with the statement of Ross (1970) that repair of the cleft palate by any surgical technique will result in inhibition of the growth of the maxillary complex.
In conclusion, the present study that the Gothenburg DHPC protocol in patients with complete UCLP results in more normal anterior maxillary vertical growth and overbite, and therefore increased maxillary inclination at 10 years of age.
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