A cephalometric intercentre comparison of patients with unilateral cleft lip and palate at 5 and 10 years of age

The aim of this study was to evaluate any differences between the craniofacial growth of unilateral cleft lip and palate (UCLP) patients who underwent surgery in the Milan CLP centre with those from the Oslo CLP centre at 5 and 10 years of age. The Milan sample comprised 88 UCLP patients (60 males, 28 females) at 5 years of age and 26 patients (17 males, 9 females) at 10 years of age all operated on by the same surgeon. The Oslo sample consisted of 48 UCLP patients (26 males, 22 females) aged 5 years and 29 patients (20 males, 9 females) aged 10 years treated by four different surgeons. Lateral cephalometric radiographs obtained for both samples were analysed and angular measurements and ratios were calculated both for the hard and soft tissues. Statistical analysis was undertaken with an unpaired t-test. At 5 years of age, there were neither sagittal nor vertical hard tissue differences between the two groups. With regard to the soft tissues, only the naso-labial angle showed a statistically significant difference (Milan greater than Oslo by 5 degrees, P < 0.01). At 10 years of age, both SNA and ANB differences were larger in the Oslo group than in the Milan group, >2.6 degrees, P < 0.01 and >2.9 degrees, P < 0.001, respectively. At 5 years of age, the Milan UCLP sample had the same maxillary protrusion as the Oslo group, while at 10 years of age, the Milan sample were slightly less protruded than the Oslo group.

However, no consensus has been reached as to the cause of this growth inhibition. Surgical treatment is viewed as the variable most infl uencing craniofacial growth ( Ross, 1987 ;Shaw et al. , 1992 ).
It is still controversial as to which type of surgical repair most negatively infl uences growth. Some authors ( Bardach and Mooney, 1984 ;Kapuçu et al. , 1996 ;Capelozza Filho et al. , 1996 ;Huang et al ., 2002 ) consider lip closure as the most important factor responsible for maxillary growth restriction, while others palatal surgery ( Ross, 1987 ;Liao and Mars, 2005 ).
Secondary bone grafting is carried out usually before the eruption of the canines or, in some centres, before the eruption of the permanent maxillary lateral incisors ( Eldeeb et al. , 1986 ;Bergland et al. , 1986 ;Lilya et al. , 2000 ). According to Semb (1988) , secondary bone grafting after 8 years of age does not have any adverse infl uence on anteroposterior or vertical maxillary growth, while Enemark et al. (1987) and Daskalogiannakis and Ross (1997) report a negative infl uence on vertical growth when bone grafting is performed before 10 -11 years of age.
The iatrogenic effect of surgical repair, on the other hand, has been shown to be strongly linked to the experience of the surgeons and their surgical skill ( Shaw et al. , 1992 ).
Intercenter studies allow for comparison between different surgical protocols applied in different centres in order to defi ne the protocol from which the best results in terms of growth, dental occlusion, and aesthetics can be obtained ( Shaw et al. , 1992 ).
The results for the Oslo centre have been previously compared with other European centres and maxillary growth of the subjects has been shown to be among the best in Europe ( Molsted et al. , 1992 ).
The Milan surgical protocol consists of lip, nose, and soft palate repair at 4 -6 months of age ( Brusati and Mannucci, 1992 ) and early secondary gingivoalveoloplasty (ESGAP) at 18 -36 months of age during hard palate repair. Presurgical orthopaedics are performed in 60 per cent of patients. The Milan ESGAP seems to allow for excellent ossifi cation (no necessity for secondary bone grafting), but at this time, it is not possible to determine its infl uence on maxillary growth ( Meazzini et al. , 2007 ).
A cephalometric intercentre comparison of patients with unilateral cleft lip and palate at 5 and 10 years of age Filomena Del Guercio * , Maria Costanza Meazzini * , Giovanna Garattini ** , Alberto Morabito *** , Gunvor Semb **** and Roberto Brusati * * Department of Maxillo-Facial Surgery, University of Milan, Regional Center for CLP , Departments of ** Orthodontics and *** Biomedical Statistics, San Paolo Hospital, Milan, Italy and **** Oslo Cleft Team, Department of Plastic Surgery, National Hospital, Norway SUMMARY The aim of this study was to evaluate any differences between the craniofacial growth of unilateral cleft lip and palate (UCLP) patients who underwent surgery in the Milan CLP centre with those from the Oslo CLP centre at 5 and 10 years of age.
The Milan sample comprised 88 UCLP patients (60 males, 28 females) at 5 years of age and 26 patients (17 males, 9 females) at 10 years of age all operated on by the same surgeon. The Oslo sample consisted of 48 UCLP patients (26 males, 22 females) aged 5 years and 29 patients (20 males, 9 females) aged 10 years treated by four different surgeons. Lateral cephalometric radiographs obtained for both samples were analysed and angular measurements and ratios were calculated both for the hard and soft tissues. Statistical analysis was undertaken with an unpaired t -test.
At 5 years of age, there were neither sagittal nor vertical hard tissue differences between the two groups. With regard to the soft tissues, only the naso-labial angle showed a statistically signifi cant difference (Milan greater than Oslo by 5 degrees, P < 0.01). At 10 years of age, both SNA and ANB differences were larger in the Oslo group than in the Milan group, >2.6 degrees, P < 0.01 and >2.9 degrees, P < 0.001, respectively.
At 5 years of age, the Milan UCLP sample had the same maxillary protrusion as the Oslo group, while at 10 years of age, the Milan sample were slightly less protruded than the Oslo group.

INTERCENTRE COMPARISON OF CLEFT PATIENTS
The Oslo CLP team use a different surgical protocol including lip closure (Millard procedure) at 3 months of age with hard palate repair by a one-layer vomer fl ap without any pre-surgical orthopaedics, and posterior palate closure at 18 months of age according to von Langenbeck ( Semb, 1991 ). The alveolar cleft is repaired with a bone graft between 8 and 11 years of age ( Bergland et al. , 1986 ).
The objective of this study was to determine whether there is any difference between the craniofacial growth of unilateral cleft lip and palate (UCLP) patients treated in the Milan CLP centre and those patients from the Oslo CLP centre at 5 and 10 years of age.

Subjects and methods
The Milan 5-year-old sample comprised 88 consecutively treated UCLP (60 males, 28 females) non-syndromic patients, with an average age of 5 years 1 month, all operated on by the same surgeon, and the 10-year-old sample 26 consecutively treated UCLP (17 males, 9 females) nonsyndromic patients, with an average age of 9 years 10 months, all operated by the same surgeon. None of the subjects were omitted from the sample because of missing records or other reasons. All patients were Caucasian and of Italian origin.
The Oslo 5-year-old sample comprised 48 consecutively treated UCLP (26 males, 22 females) non-syndromic patients with an average age of 5 years 9 months and 29 consecutively treated UCLP (20 males, 9 females) nonsyndromic patients, with an average age of 10 years treated by four different surgeons. All subjects were Caucasian of Norwegian origin.
Lateral cephalometric radiographs were obtained for both groups at 5 and 10 years of age. The radiographs ( Figure 1) were traced by one trained operator (FDG).
The parameters evaluated on the lateral radiographs are listed in Table 1 . Linear measurements were not compared as absolute values, as it was not possible to calculate the radiographic magnifi cation obtained with different machines, since the technical parameters were not reported.

Statistical analysis
An unpaired t -test was used to determine any differences between the two samples. The same experienced operator retraced, after an interval of 1 month, 25 blindly selected radiographs to avoid bias linked to groups. Method error analysis was carried out using the formula of Dahlberg (1940) . For all variables, the measurement error was less than 3 per cent of the total variance. Furthermore, systematic error was estimated with a one-sample t -test, while random error was evaluated through the coeffi cient of reliability as suggested by Houston (1983) .

Five years of age
Hard tissue variables. Sagittal dimensions. There was no signifi cant difference in maxillary prominence, although in the sagittal jaw relationship, there was a statistically signifi cant difference between the Milan and Oslo UCLP samples ( Table 1 ). There was no signifi cant difference in cranial base angulation ( P > 0.05).
Vertical dimensions. There was no signifi cant difference in palatal inclination. Craniomandibular, intermaxillary, and mandibular angles were signifi cantly larger in the Milan UCLP sample ( P < 0.001).

Soft tissue variables.
There was no signifi cant difference in the sagittal protrusion of the upper lip, while the sagittal

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interlip relationship in the Milan group was signifi cantly smaller than in the Oslo sample ( Table 1 ). Naso-labial angle was larger in the Milan UCLP sample and the difference was statistically signifi cant ( P < 0.01).

Ten years of age
Hard tissue variables. Sagittal dimensions. There was a signifi cant difference in maxillary prominence and in sagittal jaw relationship between the Milan and Oslo samples ( P < 0.01; Table 1 ). The Oslo UCLP sample was more protruded than the Milan sample at the dentoalveolar level, although there was no difference in the protrusion of anterior nasal spine.
Vertical dimensions. There was no signifi cant difference in any of the vertical dimensions.
Soft tissue variables. The sagittal relationship was signifi cantly less favourable in the Milan UCLP sample compared with the Oslo UCLP sample ( P < 0.001; Table 1 ).

Discussion
The results of the present study showed no differences in maxillary protrusion at 5 years of age between the two groups.
These data confi rm cephalometrically the fi ndings obtained using the 5-year yardstick by Flinn et al. (2006) , where the 5-year-old dental arch relationship of patients from three different centres (Oslo, Norway; Milan, Italy; and Lancaster, Pennsylvania, USA) were compared. The results showed that between the three centres there were no statistically signifi cant differences, even though the protocols differed.
In this study, the Milan sample showed a more divergent mandibular pattern and a more open gonial angle than the Oslo sample, demonstrating a different pattern of mandibular growth. Semb (1988) reported that after bone grafting there was a tendency towards posterior rotation of the mandible. Furthermore, Trotman et al. (1996) found that in patients who had undergone primary grafting, the mandibular growth pattern was different from the non-grafted group with a clockwise rotation of the mandible. ESGAP might therefore explain the difference in mandibular rotation. This apparent mandibular compensation which differentiated the Milan sample from the Oslo sample at 5 years of age was not signifi cant at 10 years of age. A possible explanation might be that by 10 years of age, most of the Oslo sample had undergone secondary bone grafting.
The present results show that at 10 years of age, the Oslo sample was signifi cantly more protruded at the maxillary dentoalveolar level than the Milan sample, although, there was no difference in protrusion of anterior nasal spine. Soft tissue differences confi rmed a larger upper lip protrusion for the Oslo sample. At present, there is no explanation for this dentoalveolar growth difference at 10 years of age. The improved growth of the Oslo group compared with the Milan sample might be related to the different surgical protocols. Intrinsic racial differences might also be a confounding factor. Although there are cephalometric studies on the Norwegian population ( El-Batouti et al. , 1994 ;Axelsson et al. , 2003 ), no data exist on craniofacial growth of Italians. There is a great variability in the Italian race due to Spanish and Austro-Hungarian domination in Northern Italy and Swedish domination in Southern Italy, but no studies have analysed this variability. Certainly, long-term data will be needed for a more defi nitive conclusion.
by guest on November 14, 2015