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Soft tissue profile changes after Le Fort I osteotomy in UCLP patients
Journal of Cranio-Maxillofacial Surgery (2000) 28, 25±30 # 2000 European Association for Cranio-Maxillofacial Surgery doi:10.1054/jcms.1999.0109, available online at http://www.idealibrary.com on
Soft tissue pro®le changes after Le Fort I osteotomy in UCLP patients Arja HelioÈvaara, Jyri Hukki, Reijo Ranta, Aarne Rintala Cleft Centre, Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland, (Head: Sirpa Asko-Seljavaara, Professor of Plastic Surgery) SUMMARY. The changes in soft tissue pro®le after Le Fort I osteotomy were evaluated cephalometrically in 38 consecutive UCLP patients (25 males, 13 females) operated on between 1987 and 1995. Mean age at operation was 23.5 years. The one-piece Le Fort I osteotomy was ®xed with titanium plates and the osteotomy site was bone grafted. Neither intermaxillary ®xation nor occlusal splints were used postoperatively. Soft tissue changes were analyzed both horizontally and vertically by cephalograms taken shortly before surgery, 6 months and 1 year postoperatively. The mean maxillary skeletal advancement (point A) during surgery was 3.8 mm and mean vertical lengthening 4.4 mm. One year postoperatively the horizontal change in the upper lip pro®le (point a) was 80% of the skeletal change. Vertically, the soft tissue change in the upper lip was smaller 40%, but increased signi®cantly (to 58%) if V-Y plasty was used. The V-Y plasty also increased the anteroposterior thickness of the upper lip. No signi®cant soft tissue changes were observed between 6 months and 1 year postoperatively. # 2000 European Association for Cranio-Maxillofacial Surgery
INTRODUCTION
Plastic Surgery, Helsinki University Central Hospital between 1987 and 1995. The mean age of the patients at operation was 23.5 years (range 16.3±40.4). Most of the clefts (23) were on the left side. The initial series comprised 60 UCLP consecutive patients but 22 patients were excluded because of syndromes (two), combined clefts (three), missing (12) or inadequate quality X-rays (three), or secondary lip operations during the ®rst postoperative year (two). The primary operations for the cleft of the lip were performed at the age of 3±6 months by a total of 10 surgeons between the years 1953 to 1978. Preliminary lip adhesion had been utilized in eight patients. The methods for ®nal lip closure varied from modi®cations of Veau, Le Mesurier, and Skoog to Millard I and II. Periosteal ¯aps were utilized in six and periosteal grafts in two patients to close the alveolar clefts. No primary bone grafting was used. The method for palatal closure at the age of 1.5 to 2 years was either the Veau-Wardill-Kilner or a Cronin push back procedure. All but one of the patients had secondary operations prior to the Le Fort I osteotomy. Secondary bone grafting of the alveolar cleft was performed in 31 patients between the ages of 10±17 years. Other secondary procedures included rhinoplasty (33), closure of ®stula (28 frequently in connection with bone grafting), lip correction (25) and velopharyngoplasty (7). The number of secondary operations prior to the maxillary osteotomy varied from 0±12 with a mean of four per patient. Patients had received orthodontic treatment in the mixed and early permanent dentitions.
Typically, the cleft patients scheduled for orthognathic surgery exhibit midface de®ciency, both horizontally and vertically. Lack of normal cheek contour, nasolabial imbalance, lack of nasal tip projection and lack of upper lip support contribute to the facial appearance (Turvey et al., 1996). In unilateral cleft lip and palate patients asymmetries may further complicate the situation. Although maxillary de®ciency adversely aects occlusion and function, the improvement of facial aesthetics is a major goal for the patient seeking maxillary surgery. However, maxillary osteotomy, particularly advancement and vertical lengthening, may lead to vertical shortening and anteroposterior thinning of the upper lip. In has been shown (Wolford, 1992) that V-Y plasty can be used to control these unfavourable changes in the upper lip. It is obvious that knowledge of soft tissue changes and stability of the surgical results are of crucial importance. This paper is part of a retrospective series that examines stability and soft tissue changes after Le Fort I osteotomy in cleft patients. The purpose of this study was to examine the soft tissue response following Le Fort I osteotomy with and without V-Y plasty in UCLP patients, and to assess the longterm stability of the soft tissue changes. MATERIAL AND METHODS Patients
Cephalometric measurements
The series consisted of 38 Finnish patients (25 males, 13 females) with UCLP who had undergone a Le Fort I osteotomy at the Cleft Centre, Department of
Standardized lateral cephalometric radiographs, taken with the head positioned with the Frankfort 25
26 Journal of Cranio-Maxillofacial Surgery
plane, with molar teeth occluded and lips in repose. The radiographs were taken shortly before surgery (T1), immediately after surgery (T2), 6 months (T3) (mean 6.1 months, range 4.5±7.9 months, SD=25.1 days) and one year (T4) (mean 1.1 year, range 0.9±1.4 years, SD=49.2 days) postoperatively. When analyzing the postoperative soft tissue changes the T3 and T4 ®lms were used to avoid the period of postoperative oedema and to ensure that soft tissue stability was established. The cephalograms were digitised twice, the computer being programmed to calculate the mean of the two recordings. The subsequent cephalometric tracings were superimposed on the structures of anterior cranial base. The change in maxillary position was established by superimposing a template of the preoperative outline of the maxilla on subsequent radiographs using anatomical best ®t. To dierentiate horizontal and vertical changes an x±y coordinate system was used. The x-axis was determined as a line through Nasion rotated 78 upwards from the Sella-Nasion-line. The y-axis was determined as a vertical line perpendicular to the horizontal line through Sella. The reference points and landmarks are shown in Figure 1. All measurements were corrected for cephalometric enlargement. For analysis of the surgical changes, cephalometric linear dimensions and angles as well as the linear distance of each landmark (pre- and postoperative) from both the horizontal and vertical reference planes were calculated. Point A was used to calculate the mean maxillary (skeletal) surgical change and postoperative relapse. There was signi®cant variation in the distance PM-ANS pre- and postoperatively as the anterior nasal spine was often altered during surgery. Accordingly, the reference point ANS was omitted (HelioÈvaara et al. [in press]). Surgical technique and orthodontics The patients of this study (1987±1995) were treated by four surgeons and one senior orthodontist. Since 1994 the surgery was performed by one surgeon. The osteotomies were grafted using bone from iliac crest and ®xed with titanium plates. Prefabricated interocclusal splints were used during surgery to determine the occlusion. After surgery the splint was removed immediately. No postoperative IMF was applied. During Le Fort I osteotomy the maxilla was moved forward and downward, while the mandible rotated correspondingly clockwise. On average the maxilla (point A) was advanced 3.8 mm (range 0±8.9 mm) and moved inferiorly 4.4 mm (range 70.6±10.5 mm). The skeletal changes and the surgical technique are reported in detail in another article (HelioÈvaara et al. [in press]). During 1994 and 1995 a V-Y plasty was performed whenever indicated to increase the vertical length of the upper lip in order to allow optimal maxillary downward rotation without a risk of excess incisor
Fig. 1 ± Cephalometric landmarks. Abbreviations, full names and de®nitions. A (point A): deepest point on the anterior contour of the maxillary alveolar arch. a (soft tissue point a): deepest point on the soft tissue contour of the upper lip. ANS (anterior nasal spine): tip of anterior nasal spine. B (point B): deepest point on the anterior contour of the mandibular alveolar arch. b (soft tissue point b): deepest point of the soft tissue contour of the lower lip. cm (columnella): the most anterior point of the columnella of the nose. gn (soft tissue gnathion): lowest point of soft tissue chin. ID (infradentale): the most antero-superior point on the lower dentoalveolar margin. li (labrale inferior): most anterior point of the lower lip. ls (labrale superior): most anterior point of the upper lip. N (nasion): most anterior point on the nasofrontal suture. n: (soft tissue nasion): most concave point in the tissue overlying the area of the frontonasal suture. PM (pterygomaxillare): intersection between nasal ¯oor and the posterior contour of maxilla. POG (pogonion): most prominent point of the bony chin. pog (soft tissue pogonion): most anterior point of soft tissue chin PR (prosthion): the most anteroinferior point on the upper dentoalveolar margin. prn (pronasale): most prominent point of apex nasi. S (sella): centre of sella turcica. sn (subnasale): point at which columnella merges with upper lip. X-axis: horizontal line through N rotated 78 upwards from the Sella-Nasion-line. Y-axis: vertical line perpendicular to the horizontal line through Sella.
show. In addition to increasing the vertical upper lip length, the procedure was performed to give extra fullness of the lip for better pro®le. In this procedure the orbicularis muscles were sutured in the midline using slowly resorbable material. The mucosa was closed separately. During the Le Fort I osteotomy simultaneous sagittal split osteotomy was carried out in four patients and simultaneous rhinoplasty in ®ve patients. During the ®rst postoperative year eight patients had secondary procedures: seven patients
Soft tissue pro®le changes after Le Fort I osteotomy in UCLP patients 27
had rhinoplasty and one underwent closure of oronasal ®stula. All patients received orthodontic treatment before and/or after the osteotomy. During postoperative orthodontics intermaxillary elastics were used individually for minor correction of intercuspidation. For orthodontic retention of maxillary dental arch removable retainers and ®xed horse shoe palatal arches were used. In a few cases the upper arch was stabilized with a ®xed prosthesis. Statistical methods Student's t-test was used in the statistical analysis. p-values equal or less than 0.05 were considered statistically signi®cant. RESULTS Mean soft tissue change as a percentage of skeletal change one year postoperatively is given in Figure 2. In the upper lip area changes were less than in the lower lip and `mandibular area'. Horizontally the mean change in the upper lip pro®le (point a) was 80% of the skeletal change. Vertically the mean soft tissue change in the upper lip was smaller, 40%. However, vertical changes increased signi®cantly if
V-Y plasty was used. Before 1994 (without V-Y plasty) the corresponding soft tissue change was 30% but after 1994 (with V-Y plasty) the vertical soft tissue change of point a increased to 58% (Fig. 3). The V-Y plasty also increased the anteroposterior thickness of the upper lip (Pr-ls) by 1 mm so that no signi®cant thinning ( p50.016) of the upper lip occurred during surgery. In the lower lip and `mandibular area' the soft tissue changes were almost 100% horizontally. Vertically the soft tissue change exceeded 100%. A simultaneous rhinoplasty (used during 1994±1995) had no statistically signi®cant eect on any of the cephalometric soft tissue changes during the same age period. This enabled us to combine all data in the analysis. Surgical changes in cephalometric angles and measurements of facial height are given in Table 1. There was a signi®cant change of facial convexity, nasolabial angle and of facial height. No signi®cant soft tissue changes were observed between 6 months and 1 year postoperatively. Surgical changes, i.e. distances of the cephalometric landmarks from the horizontal and vertical reference planes are shown in Table 2. The horizontal soft tissue changes were only statistically signi®cant in the upper lip area. Vertically the soft tissue changes were only statistically signi®cant in the lower face. No signi®cant changes were observed between 6 months and 1 year postoperatively. DISCUSSION
Fig. 2 ± Mean soft tissue change as percent of skeletal change one year postoperatively. a-A; ls-PR; & li-ID; b-B; & pogPOG.
Fig. 3 ± Soft tissue change in upper lip pro®le (point a as percent of point A movement) one year postoperatively with and without V-Y plasty. no V-Y plasty (n=25); with V-Y plasty (n=13); mean.
Facial harmony and a well-balanced pro®le is an essential goal of orthognathic surgery. The present study showed statistically signi®cant soft tissue improvement in facial convexity, nasolabial angle and upper lip prominence associated with Le Fort I osteotomy and associated procedures in cleft patients. As in previous studies (Willmar, 1974; Freihofer, 1976, 1977; Araujo et al., 1978; Ewing and Ross, 1993; Hui et al., 1994; Al-Waheidi et al., 1998), there was great individual variation. A major ®nding in our study was that from 6 months to 1 year postoperatively, there were no statistically signi®cant changes in any of the soft tissue measurements. Ewing and Ross (1993) reported that following maxillary advancement in cleft patients, the overall soft tissue changes were minute after the ®rst year. This is in agreement with previous cleft studies dealing with skeletal relapse (Araujo et al., 1978; Epker et al., 1981; Houston et al., 1989). For relapse tendencies, scarring, muscle pull, soft tissue tension, adaptation and stability of bony fragments are the principal factors (Hochban et al., 1993). Maxillary surgery may result in unpleasing nasal and labial changes. Typically, there is widening of the nasal base and associated ¯attening and thinning of the upper lip (Schendel and Carlotti, 1991). The asymmetrical cleft deformities of nose and lip may further complicate the situation. However, it is impossible to establish adequate nasal projection or lip prominence
28 Journal of Cranio-Maxillofacial Surgery Table 1 ± Postoperative cephalometric changes (and signi®cances). Angles are reported in degrees and distances in millimetres. T1=immediate preoperatively, T3=6 months postoperatively, T4=1 year postoperatively UCLP
T1
T3
T4
T1/T3
T3/T4 p-value
n=38
mean
SD
mean
SD
mean
SD
p-value
S-n-a S-n-b S-n-pog n-sn-pog n-prn-pog cm-sn-ls n-gn n-sn sn-gn sn-stou sn-ls
87.8 87.2 89.3 174.5 138.2 81.5 117.6 49.8 68.2 18.9 14
4.3 4.6 4.8 4.7 5.1 13.5 8.4 3.6 6.1 2.9 2.6
90.7 85.7 87.6 171.7 133.2 93.5 120.4 50.5 71.3 21.8 16
3.7 3.8 4 5.3 5.9 13 8.1 4.7 5.9 2.4 2.6
90 85.3 87.2 172.5 133.5 90.5 120.7 51.3 70.5 21.4 15.4
4.6 4.4 4.4 4.8 5.2 11 8 4.3 5.8 2.1 2.3
0.003 0.121 0.092 0.018 0 0 0.147 0.451 0.028 0 0.001
0.423 0.691 0.751 0.482 0.841 0.292 0.853 0.473 0.576 0.445 0.488
A-a Pr-ls ID-li B-b POG-pog
14.2 15.2 16.2 11.4 13.4
2.4 2.9 2 1.2 2.9
13.3 13.7 16.1 11.4 13.2
2.5 2.4 2.2 1.4 2.7
13.4 14.3 16.5 11.7 13.1
2.5 2.6 2.3 1.4 3.2
0.109 0.016 0.834 0.99 0.757
0.854 0.309 0.474 0.816 0.957
Statistically signi®cant results ( p=50.05) in bold.
Table 2 ± Changes and signi®cances of the distances (mm) of each cephalometric landmark from the horizontal and vertical reference planes. The mean surgical change (mm) is given in the last two columns. T1=immediate preoperatively, T3=6 months postoperatively, T4=1 year postoperatively UCLP n=38 Horizontal stability prn-Y sn-Y cm-Y a-Y ls-Y li-Y b-Y pog-Y gn-Y Vertical stability prn-X sn-X cm-X a-X ls-X li-X b-X pog-X gn-X
T1
T3
T4
T1/T3
T3/T4
T37T1
T47T3
mean
SD
mean
SD
mean
SD
p-value
p-value
93.7 74.1 85.8 73.6 76.7 80.8 72.8 76.5 67.4
5.8 5.4 5.8 5.3 6 7.1 8.3 10.1 11.6
95.2 76.9 88.6 76.3 78.5 79.2 70.5 73.5 64.2
4.7 4.1 5 4.2 5.1 6.5 7 8.6 9.8
95.4 76.4 88.1 76 78.5 79.1 70.4 73.6 63.7
4.7 4.4 4.9 4.6 5.2 6.6 7.4 9.1 9.1
0.221 0.016 0.027 0.016 0.179 0.294 0.302 0.179 0.196
0.851 0.638 0.614 0.761 0.941 0.996 0.961 0.984 0.762
1.5 2.8 2.8 2.7 1.8 71.6 72.3 73 73.2
70.2 70.5 70.5 70.3 0 70.1 70.1 0.1 70.5
37.4 46.3 45.7 50.2 59.8 72.9 84.3 100 113.6
4.2 3.4 4 3.6 4.6 6.4 5.9 6.9 7.6
37.1 46.9 44.9 51.2 62.6 76.5 87 103.2 116.5
4.2 3.6 3.9 3.9 4.4 5.3 5.3 6.6 6.9
37.2 47.2 45.4 51.7 62.5 76.4 87.2 103.7 116.5
3.9 3.4 3.8 3.7 4.1 5.2 5.4 6.2 6.9
0.735 0.424 0.38 0.275 0.009 0.011 0.042 0.044 0.099
0.95 0.685 0.61 0.578 0.917 0.993 0.877 0.727 0.994
70.3 0.6 70.8 1 2.8 3.6 2.7 3.2 2.9
0.1 0.3 0.5 0.5 70.1 70.1 0.2 0.5 0
Statistically signi®cant results ( p50.05) in bold.
relative to other facial features without reconstructing the underlying skeletal de®ciency. In this study ®ve patients underwent open rhinoplasty simultaneously with the Le Fort I procedure whilst 28 patients required nasal correction in a subsequent operation. This underscores the importance of cleft rhinoplasty in conjunction with the Le Fort I procedure. It is of interest that simultaneous rhinoplasty had no signi®cant eect on the lateral cephalometric soft tissue measurements. This may be explained by the rhinoplasty technique which in
pro®le has its main eects on the nasal dorsum and superior to the nasal tip. It is also obvious that cleft nasal deformity and the eects of rhinoplasty cannot be analyzed by lateral cephalograms only, and should be analyzed by other methods such as photographs and or computer imaging since these radiographs can only give a two-dimensional image of a threedimensional problem. Following Le Fort I osteotomy in unilateral cleft lip and palate patients, three dimensional analyses have shown that there was a greater degree of movement on the cleft side than the
Soft tissue pro®le changes after Le Fort I osteotomy in UCLP patients 29
noncleft side (McCance et al., 1997). Moreover, when small surgical changes are evaluated, method error may complicate interpretation of the data especially when the sample size is also small. When soft and hard tissue changes are within 1 or 2 mm, the measurement error becomes more critical (Mansour et al., 1983). Advancement of the small cleft maxilla improves upper lip support. The repaired cleft lip is thinner and less ¯exible (Ewing and Ross, 1993) and residual aesthetic and functional deformities may exist. Previous investigations (Ewing and Ross, 1993) have shown that the upper lip thinned with maxillary advancement but this was not related statistically to the original lip thickness. According to Al-Waheidi et al., (1998) upper lip length increased but upper lip thickness decreased following maxillary advancement. Simultaneous mandibular surgery had no appreciable eect on upper lip movement (Eskenazi and Schendel, 1992). Many authors have used changes in upper lip/ upper incisor relationship to describe the soft tissue changes. Ratios from 0.29 : 1 to 0.75 : 1 have been reported (Willmar, 1974; Freihofer, 1976; Araujo et al., 1978; Ewing and Ross, 1993; Hui et al., 1994). According to Al-Waheidi et al. (1998) the upper incisor position was the most common predictor of signi®cant soft tissue change but accounted for less than 50% of the variablity of the change of all soft tissue points. One possible diculty with the use of upper incisor tip is that postoperative orthodontics or prosthetic rehabilitation may change the upper incisor inclination postoperatively. In this study soft tissue point a and prosthion were used as reference points. Horizontal change in the upper lip pro®le was 60±80% of skeletal change. Vertically, the changes in the upper lip area were smaller, but increased signi®cantly if V-Y plasty was used. Furthermore, the upper lip thickness increased signi®cantly if V-Y plasty was used. The addition of V-Y plasty minimizes vertical shortening and maintains greater anteroposterior thickness of the upper lip. A V-Y closure also improves upper lip aesthetics (Wolford, 1992). Lip fullness and smile line are essential when judging the aesthetic pro®le. Ideal female and male soft tissue pro®les as described in fashion magazines have favoured greater lip fullness through the 20th century (Nguyen & Turley, 1998; Auger & Turley, 1999). On the other hand Bishara et al., (1998) have noted that the upper and lower lips become signi®cantly more retruded between 15 and 45 years. Repositioning of the maxilla changes the incisor exposure and appearance of the lips. Prior to the maxillary osteotomy the cleft patients typically have low smile-lines and poor incisor display. This can be related to skeletal and soft-tissue de®ciency as well as muscular function and pre-existing scar tissue. Characteristically, the patients have learned to smile and speak without incisor show. In our experience simultaneous V-Y plasty can be used to compensate for unfavourable changes in the lip that may result from maxillary procedures. The
results can be considered stable as no signi®cant soft tissue changes were observed between 6 months and 1 year postoperatively. The skeletal vertical relapse of these patients with V-Y plasty one year postoperatively was 8% (HelioÈvaara et al. [in press]). Preoperatively careful assessment of the vertical change in the upper lip is important regarding upper incisor exposure and the smile line. It is often dicult to predict preoperatively the absolute vertical postoperative situation. The ®nal evaluation of the maxillary vertical lengthening, incisor display and upper lip lengthening can be assessed during surgery. This does not completely eliminate the need for secondary lip/nose correction but can diminish the number of secondary revisions.
References Al-Waheidi EMH, Harradine NWT, Orth M: Soft tissue pro®le changes in patients with cleft lip and palate following maxillary osteotomies. Cleft Palate Craniofac J 35: 535±543, 1998 Araujo A, Schendel SA, Wolfort, LM, Epker BN: Total maxillary advancement with and without bone grafting. J Oral Surg 36: 849±858, 1978 Auger TA, Turley PK: The female soft tissue pro®le as presented in fashion magazines during the 1900s: a photographic analysis. Int J Adult Orthodon Orthognath Surg 14: 7±18, 1999 Bishara SE, Jakobsen JR, Hession TJ, Treder JE: Soft tissue pro®le changes from 5 to 45 years of age. Am J Orthod Dentofac Orthop 114: 698±706, 1998 Epker BN: Superior surgical repositioning of the maxilla: long term results. J Oral Maxillofac Surg 9: 237±246, 1981 Eskenazi LB, Schendel SA: An analysis of Le Fort I maxillary advancement in cleft lip and palate patients. Plast Reconstr Surg 90: 779±786, 1992 Ewing M, Ross RB: Soft tissue response to orthognathic surgery in persons with unilateral cleft lip and palate. Cleft Palate Craniofac J 30: 320±327, 1993 Freihofer HPM Jr: The lip pro®le after correction of retromaxillism in cleft and non-cleft patients. J Maxillofac Surg 4: 136±141, 1976 Freihofer HPM Jr: Changes in nasal pro®le after maxillary advancement in cleft and non-cleft patients. J Maxillofac Surg 5: 20±27, 1977 HelioÈvaara A, Ranta R, Hukki J, Rintala A: Skeletal stability of Le Fort I osteotomy in UCLP patients. Scand J Plast Reconstr Hand Surg, in press Hochban W, Ganss C, Austermann KH: Long-term results after maxillary advancement in patients with clefts. Cleft Palate Craniofac J 30: 237±243, 1993 Houston WJB, James DR, Jones E, Kavvadia S: Le Fort I maxillary osteotomies in cleft palate cases. Surgical changes and stability. J CranioMaxillofac Surg 17: 9±15, 1989 Hui E, HaÈgg EU, Tideman H: Soft tissue changes following maxillary osteotomies in cleft lip and palate and non-cleft patients. J Cranio-Maxillofac Surg 22: 182±186, 1994 Mansour S, Burstone C, Legan H: An evaluation of soft-tissue changes resulting from Le Fort I maxillary surgery. Am J Orthod 84: 37±47, 1983 McCance AM, Orth M, Moss JP et al: Three-dimensional analysis techniques ± Part 4: three-dimensional analysis of bone, and soft tissue to bone ratio of movements in 24 cleft patients following Le Fort I osteotomy: a preliminary report. Cleft Palate Craniofac J 43: 58±62, 1997 Nguyen DD, Turley PK: Changes in the Caucasian male facial pro®le as depicted in fashion magazines during the twentieth century. Am J Orthod Dentofac Orthop 114: 208±217, 1998 Schendel SA, Carlotti AE: Nasal considerations in orthognathic surgery. Am J Orthod Dentofac Orthop 100: 197±208, 1991
30 Journal of Cranio-Maxillofacial Surgery Turvey TA, Vig KWL, Fonseca RJ: Maxillary advancement and contouring in the precence of cleft lip and palate. In: Turvey TA, Vig KWL, Fonseca RJ (Eds): Facial clefts and craniosynostosis. Principles and management. Philadelphia: Saunders, 1996; 441±503 Willmar K: On Le Fort I osteotomy: A follow-up study of 106 operated patients with maxillo-facial deformity. Scand J Plast Reconstr Surg 12 (suppl 1): 1±68, 1974 Wolford LW: Eects of orthognathic surgery on nasal form and function in the cleft patient. Cleft Palate Craniofac J 29: 546±555, 1992
Arja HelioÈvaara Cleft Centre Department of Plastic Surgery Helsinki University Central Hospital Topeliuksenkatu 5 FI 00260 Helsinki Finland Tel: 358 9 471 87247 Fax: 358 9 471 87654 Paper received 6 July 1999 Accepted 7 February 2000
Soft tissue pro®le changes after Le Fort I osteotomy in UCLP patients Arja HelioÈvaara, Jyri Hukki, Reijo Ranta, Aarne Rintala Cleft Centre, Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland, (Head: Sirpa Asko-Seljavaara, Professor of Plastic Surgery) SUMMARY. The changes in soft tissue pro®le after Le Fort I osteotomy were evaluated cephalometrically in 38 consecutive UCLP patients (25 males, 13 females) operated on between 1987 and 1995. Mean age at operation was 23.5 years. The one-piece Le Fort I osteotomy was ®xed with titanium plates and the osteotomy site was bone grafted. Neither intermaxillary ®xation nor occlusal splints were used postoperatively. Soft tissue changes were analyzed both horizontally and vertically by cephalograms taken shortly before surgery, 6 months and 1 year postoperatively. The mean maxillary skeletal advancement (point A) during surgery was 3.8 mm and mean vertical lengthening 4.4 mm. One year postoperatively the horizontal change in the upper lip pro®le (point a) was 80% of the skeletal change. Vertically, the soft tissue change in the upper lip was smaller 40%, but increased signi®cantly (to 58%) if V-Y plasty was used. The V-Y plasty also increased the anteroposterior thickness of the upper lip. No signi®cant soft tissue changes were observed between 6 months and 1 year postoperatively. # 2000 European Association for Cranio-Maxillofacial Surgery
INTRODUCTION
Plastic Surgery, Helsinki University Central Hospital between 1987 and 1995. The mean age of the patients at operation was 23.5 years (range 16.3±40.4). Most of the clefts (23) were on the left side. The initial series comprised 60 UCLP consecutive patients but 22 patients were excluded because of syndromes (two), combined clefts (three), missing (12) or inadequate quality X-rays (three), or secondary lip operations during the ®rst postoperative year (two). The primary operations for the cleft of the lip were performed at the age of 3±6 months by a total of 10 surgeons between the years 1953 to 1978. Preliminary lip adhesion had been utilized in eight patients. The methods for ®nal lip closure varied from modi®cations of Veau, Le Mesurier, and Skoog to Millard I and II. Periosteal ¯aps were utilized in six and periosteal grafts in two patients to close the alveolar clefts. No primary bone grafting was used. The method for palatal closure at the age of 1.5 to 2 years was either the Veau-Wardill-Kilner or a Cronin push back procedure. All but one of the patients had secondary operations prior to the Le Fort I osteotomy. Secondary bone grafting of the alveolar cleft was performed in 31 patients between the ages of 10±17 years. Other secondary procedures included rhinoplasty (33), closure of ®stula (28 frequently in connection with bone grafting), lip correction (25) and velopharyngoplasty (7). The number of secondary operations prior to the maxillary osteotomy varied from 0±12 with a mean of four per patient. Patients had received orthodontic treatment in the mixed and early permanent dentitions.
Typically, the cleft patients scheduled for orthognathic surgery exhibit midface de®ciency, both horizontally and vertically. Lack of normal cheek contour, nasolabial imbalance, lack of nasal tip projection and lack of upper lip support contribute to the facial appearance (Turvey et al., 1996). In unilateral cleft lip and palate patients asymmetries may further complicate the situation. Although maxillary de®ciency adversely aects occlusion and function, the improvement of facial aesthetics is a major goal for the patient seeking maxillary surgery. However, maxillary osteotomy, particularly advancement and vertical lengthening, may lead to vertical shortening and anteroposterior thinning of the upper lip. In has been shown (Wolford, 1992) that V-Y plasty can be used to control these unfavourable changes in the upper lip. It is obvious that knowledge of soft tissue changes and stability of the surgical results are of crucial importance. This paper is part of a retrospective series that examines stability and soft tissue changes after Le Fort I osteotomy in cleft patients. The purpose of this study was to examine the soft tissue response following Le Fort I osteotomy with and without V-Y plasty in UCLP patients, and to assess the longterm stability of the soft tissue changes. MATERIAL AND METHODS Patients
Cephalometric measurements
The series consisted of 38 Finnish patients (25 males, 13 females) with UCLP who had undergone a Le Fort I osteotomy at the Cleft Centre, Department of
Standardized lateral cephalometric radiographs, taken with the head positioned with the Frankfort 25
26 Journal of Cranio-Maxillofacial Surgery
plane, with molar teeth occluded and lips in repose. The radiographs were taken shortly before surgery (T1), immediately after surgery (T2), 6 months (T3) (mean 6.1 months, range 4.5±7.9 months, SD=25.1 days) and one year (T4) (mean 1.1 year, range 0.9±1.4 years, SD=49.2 days) postoperatively. When analyzing the postoperative soft tissue changes the T3 and T4 ®lms were used to avoid the period of postoperative oedema and to ensure that soft tissue stability was established. The cephalograms were digitised twice, the computer being programmed to calculate the mean of the two recordings. The subsequent cephalometric tracings were superimposed on the structures of anterior cranial base. The change in maxillary position was established by superimposing a template of the preoperative outline of the maxilla on subsequent radiographs using anatomical best ®t. To dierentiate horizontal and vertical changes an x±y coordinate system was used. The x-axis was determined as a line through Nasion rotated 78 upwards from the Sella-Nasion-line. The y-axis was determined as a vertical line perpendicular to the horizontal line through Sella. The reference points and landmarks are shown in Figure 1. All measurements were corrected for cephalometric enlargement. For analysis of the surgical changes, cephalometric linear dimensions and angles as well as the linear distance of each landmark (pre- and postoperative) from both the horizontal and vertical reference planes were calculated. Point A was used to calculate the mean maxillary (skeletal) surgical change and postoperative relapse. There was signi®cant variation in the distance PM-ANS pre- and postoperatively as the anterior nasal spine was often altered during surgery. Accordingly, the reference point ANS was omitted (HelioÈvaara et al. [in press]). Surgical technique and orthodontics The patients of this study (1987±1995) were treated by four surgeons and one senior orthodontist. Since 1994 the surgery was performed by one surgeon. The osteotomies were grafted using bone from iliac crest and ®xed with titanium plates. Prefabricated interocclusal splints were used during surgery to determine the occlusion. After surgery the splint was removed immediately. No postoperative IMF was applied. During Le Fort I osteotomy the maxilla was moved forward and downward, while the mandible rotated correspondingly clockwise. On average the maxilla (point A) was advanced 3.8 mm (range 0±8.9 mm) and moved inferiorly 4.4 mm (range 70.6±10.5 mm). The skeletal changes and the surgical technique are reported in detail in another article (HelioÈvaara et al. [in press]). During 1994 and 1995 a V-Y plasty was performed whenever indicated to increase the vertical length of the upper lip in order to allow optimal maxillary downward rotation without a risk of excess incisor
Fig. 1 ± Cephalometric landmarks. Abbreviations, full names and de®nitions. A (point A): deepest point on the anterior contour of the maxillary alveolar arch. a (soft tissue point a): deepest point on the soft tissue contour of the upper lip. ANS (anterior nasal spine): tip of anterior nasal spine. B (point B): deepest point on the anterior contour of the mandibular alveolar arch. b (soft tissue point b): deepest point of the soft tissue contour of the lower lip. cm (columnella): the most anterior point of the columnella of the nose. gn (soft tissue gnathion): lowest point of soft tissue chin. ID (infradentale): the most antero-superior point on the lower dentoalveolar margin. li (labrale inferior): most anterior point of the lower lip. ls (labrale superior): most anterior point of the upper lip. N (nasion): most anterior point on the nasofrontal suture. n: (soft tissue nasion): most concave point in the tissue overlying the area of the frontonasal suture. PM (pterygomaxillare): intersection between nasal ¯oor and the posterior contour of maxilla. POG (pogonion): most prominent point of the bony chin. pog (soft tissue pogonion): most anterior point of soft tissue chin PR (prosthion): the most anteroinferior point on the upper dentoalveolar margin. prn (pronasale): most prominent point of apex nasi. S (sella): centre of sella turcica. sn (subnasale): point at which columnella merges with upper lip. X-axis: horizontal line through N rotated 78 upwards from the Sella-Nasion-line. Y-axis: vertical line perpendicular to the horizontal line through Sella.
show. In addition to increasing the vertical upper lip length, the procedure was performed to give extra fullness of the lip for better pro®le. In this procedure the orbicularis muscles were sutured in the midline using slowly resorbable material. The mucosa was closed separately. During the Le Fort I osteotomy simultaneous sagittal split osteotomy was carried out in four patients and simultaneous rhinoplasty in ®ve patients. During the ®rst postoperative year eight patients had secondary procedures: seven patients
Soft tissue pro®le changes after Le Fort I osteotomy in UCLP patients 27
had rhinoplasty and one underwent closure of oronasal ®stula. All patients received orthodontic treatment before and/or after the osteotomy. During postoperative orthodontics intermaxillary elastics were used individually for minor correction of intercuspidation. For orthodontic retention of maxillary dental arch removable retainers and ®xed horse shoe palatal arches were used. In a few cases the upper arch was stabilized with a ®xed prosthesis. Statistical methods Student's t-test was used in the statistical analysis. p-values equal or less than 0.05 were considered statistically signi®cant. RESULTS Mean soft tissue change as a percentage of skeletal change one year postoperatively is given in Figure 2. In the upper lip area changes were less than in the lower lip and `mandibular area'. Horizontally the mean change in the upper lip pro®le (point a) was 80% of the skeletal change. Vertically the mean soft tissue change in the upper lip was smaller, 40%. However, vertical changes increased signi®cantly if
V-Y plasty was used. Before 1994 (without V-Y plasty) the corresponding soft tissue change was 30% but after 1994 (with V-Y plasty) the vertical soft tissue change of point a increased to 58% (Fig. 3). The V-Y plasty also increased the anteroposterior thickness of the upper lip (Pr-ls) by 1 mm so that no signi®cant thinning ( p50.016) of the upper lip occurred during surgery. In the lower lip and `mandibular area' the soft tissue changes were almost 100% horizontally. Vertically the soft tissue change exceeded 100%. A simultaneous rhinoplasty (used during 1994±1995) had no statistically signi®cant eect on any of the cephalometric soft tissue changes during the same age period. This enabled us to combine all data in the analysis. Surgical changes in cephalometric angles and measurements of facial height are given in Table 1. There was a signi®cant change of facial convexity, nasolabial angle and of facial height. No signi®cant soft tissue changes were observed between 6 months and 1 year postoperatively. Surgical changes, i.e. distances of the cephalometric landmarks from the horizontal and vertical reference planes are shown in Table 2. The horizontal soft tissue changes were only statistically signi®cant in the upper lip area. Vertically the soft tissue changes were only statistically signi®cant in the lower face. No signi®cant changes were observed between 6 months and 1 year postoperatively. DISCUSSION
Fig. 2 ± Mean soft tissue change as percent of skeletal change one year postoperatively. a-A; ls-PR; & li-ID; b-B; & pogPOG.
Fig. 3 ± Soft tissue change in upper lip pro®le (point a as percent of point A movement) one year postoperatively with and without V-Y plasty. no V-Y plasty (n=25); with V-Y plasty (n=13); mean.
Facial harmony and a well-balanced pro®le is an essential goal of orthognathic surgery. The present study showed statistically signi®cant soft tissue improvement in facial convexity, nasolabial angle and upper lip prominence associated with Le Fort I osteotomy and associated procedures in cleft patients. As in previous studies (Willmar, 1974; Freihofer, 1976, 1977; Araujo et al., 1978; Ewing and Ross, 1993; Hui et al., 1994; Al-Waheidi et al., 1998), there was great individual variation. A major ®nding in our study was that from 6 months to 1 year postoperatively, there were no statistically signi®cant changes in any of the soft tissue measurements. Ewing and Ross (1993) reported that following maxillary advancement in cleft patients, the overall soft tissue changes were minute after the ®rst year. This is in agreement with previous cleft studies dealing with skeletal relapse (Araujo et al., 1978; Epker et al., 1981; Houston et al., 1989). For relapse tendencies, scarring, muscle pull, soft tissue tension, adaptation and stability of bony fragments are the principal factors (Hochban et al., 1993). Maxillary surgery may result in unpleasing nasal and labial changes. Typically, there is widening of the nasal base and associated ¯attening and thinning of the upper lip (Schendel and Carlotti, 1991). The asymmetrical cleft deformities of nose and lip may further complicate the situation. However, it is impossible to establish adequate nasal projection or lip prominence
28 Journal of Cranio-Maxillofacial Surgery Table 1 ± Postoperative cephalometric changes (and signi®cances). Angles are reported in degrees and distances in millimetres. T1=immediate preoperatively, T3=6 months postoperatively, T4=1 year postoperatively UCLP
T1
T3
T4
T1/T3
T3/T4 p-value
n=38
mean
SD
mean
SD
mean
SD
p-value
S-n-a S-n-b S-n-pog n-sn-pog n-prn-pog cm-sn-ls n-gn n-sn sn-gn sn-stou sn-ls
87.8 87.2 89.3 174.5 138.2 81.5 117.6 49.8 68.2 18.9 14
4.3 4.6 4.8 4.7 5.1 13.5 8.4 3.6 6.1 2.9 2.6
90.7 85.7 87.6 171.7 133.2 93.5 120.4 50.5 71.3 21.8 16
3.7 3.8 4 5.3 5.9 13 8.1 4.7 5.9 2.4 2.6
90 85.3 87.2 172.5 133.5 90.5 120.7 51.3 70.5 21.4 15.4
4.6 4.4 4.4 4.8 5.2 11 8 4.3 5.8 2.1 2.3
0.003 0.121 0.092 0.018 0 0 0.147 0.451 0.028 0 0.001
0.423 0.691 0.751 0.482 0.841 0.292 0.853 0.473 0.576 0.445 0.488
A-a Pr-ls ID-li B-b POG-pog
14.2 15.2 16.2 11.4 13.4
2.4 2.9 2 1.2 2.9
13.3 13.7 16.1 11.4 13.2
2.5 2.4 2.2 1.4 2.7
13.4 14.3 16.5 11.7 13.1
2.5 2.6 2.3 1.4 3.2
0.109 0.016 0.834 0.99 0.757
0.854 0.309 0.474 0.816 0.957
Statistically signi®cant results ( p=50.05) in bold.
Table 2 ± Changes and signi®cances of the distances (mm) of each cephalometric landmark from the horizontal and vertical reference planes. The mean surgical change (mm) is given in the last two columns. T1=immediate preoperatively, T3=6 months postoperatively, T4=1 year postoperatively UCLP n=38 Horizontal stability prn-Y sn-Y cm-Y a-Y ls-Y li-Y b-Y pog-Y gn-Y Vertical stability prn-X sn-X cm-X a-X ls-X li-X b-X pog-X gn-X
T1
T3
T4
T1/T3
T3/T4
T37T1
T47T3
mean
SD
mean
SD
mean
SD
p-value
p-value
93.7 74.1 85.8 73.6 76.7 80.8 72.8 76.5 67.4
5.8 5.4 5.8 5.3 6 7.1 8.3 10.1 11.6
95.2 76.9 88.6 76.3 78.5 79.2 70.5 73.5 64.2
4.7 4.1 5 4.2 5.1 6.5 7 8.6 9.8
95.4 76.4 88.1 76 78.5 79.1 70.4 73.6 63.7
4.7 4.4 4.9 4.6 5.2 6.6 7.4 9.1 9.1
0.221 0.016 0.027 0.016 0.179 0.294 0.302 0.179 0.196
0.851 0.638 0.614 0.761 0.941 0.996 0.961 0.984 0.762
1.5 2.8 2.8 2.7 1.8 71.6 72.3 73 73.2
70.2 70.5 70.5 70.3 0 70.1 70.1 0.1 70.5
37.4 46.3 45.7 50.2 59.8 72.9 84.3 100 113.6
4.2 3.4 4 3.6 4.6 6.4 5.9 6.9 7.6
37.1 46.9 44.9 51.2 62.6 76.5 87 103.2 116.5
4.2 3.6 3.9 3.9 4.4 5.3 5.3 6.6 6.9
37.2 47.2 45.4 51.7 62.5 76.4 87.2 103.7 116.5
3.9 3.4 3.8 3.7 4.1 5.2 5.4 6.2 6.9
0.735 0.424 0.38 0.275 0.009 0.011 0.042 0.044 0.099
0.95 0.685 0.61 0.578 0.917 0.993 0.877 0.727 0.994
70.3 0.6 70.8 1 2.8 3.6 2.7 3.2 2.9
0.1 0.3 0.5 0.5 70.1 70.1 0.2 0.5 0
Statistically signi®cant results ( p50.05) in bold.
relative to other facial features without reconstructing the underlying skeletal de®ciency. In this study ®ve patients underwent open rhinoplasty simultaneously with the Le Fort I procedure whilst 28 patients required nasal correction in a subsequent operation. This underscores the importance of cleft rhinoplasty in conjunction with the Le Fort I procedure. It is of interest that simultaneous rhinoplasty had no signi®cant eect on the lateral cephalometric soft tissue measurements. This may be explained by the rhinoplasty technique which in
pro®le has its main eects on the nasal dorsum and superior to the nasal tip. It is also obvious that cleft nasal deformity and the eects of rhinoplasty cannot be analyzed by lateral cephalograms only, and should be analyzed by other methods such as photographs and or computer imaging since these radiographs can only give a two-dimensional image of a threedimensional problem. Following Le Fort I osteotomy in unilateral cleft lip and palate patients, three dimensional analyses have shown that there was a greater degree of movement on the cleft side than the
Soft tissue pro®le changes after Le Fort I osteotomy in UCLP patients 29
noncleft side (McCance et al., 1997). Moreover, when small surgical changes are evaluated, method error may complicate interpretation of the data especially when the sample size is also small. When soft and hard tissue changes are within 1 or 2 mm, the measurement error becomes more critical (Mansour et al., 1983). Advancement of the small cleft maxilla improves upper lip support. The repaired cleft lip is thinner and less ¯exible (Ewing and Ross, 1993) and residual aesthetic and functional deformities may exist. Previous investigations (Ewing and Ross, 1993) have shown that the upper lip thinned with maxillary advancement but this was not related statistically to the original lip thickness. According to Al-Waheidi et al., (1998) upper lip length increased but upper lip thickness decreased following maxillary advancement. Simultaneous mandibular surgery had no appreciable eect on upper lip movement (Eskenazi and Schendel, 1992). Many authors have used changes in upper lip/ upper incisor relationship to describe the soft tissue changes. Ratios from 0.29 : 1 to 0.75 : 1 have been reported (Willmar, 1974; Freihofer, 1976; Araujo et al., 1978; Ewing and Ross, 1993; Hui et al., 1994). According to Al-Waheidi et al. (1998) the upper incisor position was the most common predictor of signi®cant soft tissue change but accounted for less than 50% of the variablity of the change of all soft tissue points. One possible diculty with the use of upper incisor tip is that postoperative orthodontics or prosthetic rehabilitation may change the upper incisor inclination postoperatively. In this study soft tissue point a and prosthion were used as reference points. Horizontal change in the upper lip pro®le was 60±80% of skeletal change. Vertically, the changes in the upper lip area were smaller, but increased signi®cantly if V-Y plasty was used. Furthermore, the upper lip thickness increased signi®cantly if V-Y plasty was used. The addition of V-Y plasty minimizes vertical shortening and maintains greater anteroposterior thickness of the upper lip. A V-Y closure also improves upper lip aesthetics (Wolford, 1992). Lip fullness and smile line are essential when judging the aesthetic pro®le. Ideal female and male soft tissue pro®les as described in fashion magazines have favoured greater lip fullness through the 20th century (Nguyen & Turley, 1998; Auger & Turley, 1999). On the other hand Bishara et al., (1998) have noted that the upper and lower lips become signi®cantly more retruded between 15 and 45 years. Repositioning of the maxilla changes the incisor exposure and appearance of the lips. Prior to the maxillary osteotomy the cleft patients typically have low smile-lines and poor incisor display. This can be related to skeletal and soft-tissue de®ciency as well as muscular function and pre-existing scar tissue. Characteristically, the patients have learned to smile and speak without incisor show. In our experience simultaneous V-Y plasty can be used to compensate for unfavourable changes in the lip that may result from maxillary procedures. The
results can be considered stable as no signi®cant soft tissue changes were observed between 6 months and 1 year postoperatively. The skeletal vertical relapse of these patients with V-Y plasty one year postoperatively was 8% (HelioÈvaara et al. [in press]). Preoperatively careful assessment of the vertical change in the upper lip is important regarding upper incisor exposure and the smile line. It is often dicult to predict preoperatively the absolute vertical postoperative situation. The ®nal evaluation of the maxillary vertical lengthening, incisor display and upper lip lengthening can be assessed during surgery. This does not completely eliminate the need for secondary lip/nose correction but can diminish the number of secondary revisions.
References Al-Waheidi EMH, Harradine NWT, Orth M: Soft tissue pro®le changes in patients with cleft lip and palate following maxillary osteotomies. Cleft Palate Craniofac J 35: 535±543, 1998 Araujo A, Schendel SA, Wolfort, LM, Epker BN: Total maxillary advancement with and without bone grafting. J Oral Surg 36: 849±858, 1978 Auger TA, Turley PK: The female soft tissue pro®le as presented in fashion magazines during the 1900s: a photographic analysis. Int J Adult Orthodon Orthognath Surg 14: 7±18, 1999 Bishara SE, Jakobsen JR, Hession TJ, Treder JE: Soft tissue pro®le changes from 5 to 45 years of age. Am J Orthod Dentofac Orthop 114: 698±706, 1998 Epker BN: Superior surgical repositioning of the maxilla: long term results. J Oral Maxillofac Surg 9: 237±246, 1981 Eskenazi LB, Schendel SA: An analysis of Le Fort I maxillary advancement in cleft lip and palate patients. Plast Reconstr Surg 90: 779±786, 1992 Ewing M, Ross RB: Soft tissue response to orthognathic surgery in persons with unilateral cleft lip and palate. Cleft Palate Craniofac J 30: 320±327, 1993 Freihofer HPM Jr: The lip pro®le after correction of retromaxillism in cleft and non-cleft patients. J Maxillofac Surg 4: 136±141, 1976 Freihofer HPM Jr: Changes in nasal pro®le after maxillary advancement in cleft and non-cleft patients. J Maxillofac Surg 5: 20±27, 1977 HelioÈvaara A, Ranta R, Hukki J, Rintala A: Skeletal stability of Le Fort I osteotomy in UCLP patients. Scand J Plast Reconstr Hand Surg, in press Hochban W, Ganss C, Austermann KH: Long-term results after maxillary advancement in patients with clefts. Cleft Palate Craniofac J 30: 237±243, 1993 Houston WJB, James DR, Jones E, Kavvadia S: Le Fort I maxillary osteotomies in cleft palate cases. Surgical changes and stability. J CranioMaxillofac Surg 17: 9±15, 1989 Hui E, HaÈgg EU, Tideman H: Soft tissue changes following maxillary osteotomies in cleft lip and palate and non-cleft patients. J Cranio-Maxillofac Surg 22: 182±186, 1994 Mansour S, Burstone C, Legan H: An evaluation of soft-tissue changes resulting from Le Fort I maxillary surgery. Am J Orthod 84: 37±47, 1983 McCance AM, Orth M, Moss JP et al: Three-dimensional analysis techniques ± Part 4: three-dimensional analysis of bone, and soft tissue to bone ratio of movements in 24 cleft patients following Le Fort I osteotomy: a preliminary report. Cleft Palate Craniofac J 43: 58±62, 1997 Nguyen DD, Turley PK: Changes in the Caucasian male facial pro®le as depicted in fashion magazines during the twentieth century. Am J Orthod Dentofac Orthop 114: 208±217, 1998 Schendel SA, Carlotti AE: Nasal considerations in orthognathic surgery. Am J Orthod Dentofac Orthop 100: 197±208, 1991
30 Journal of Cranio-Maxillofacial Surgery Turvey TA, Vig KWL, Fonseca RJ: Maxillary advancement and contouring in the precence of cleft lip and palate. In: Turvey TA, Vig KWL, Fonseca RJ (Eds): Facial clefts and craniosynostosis. Principles and management. Philadelphia: Saunders, 1996; 441±503 Willmar K: On Le Fort I osteotomy: A follow-up study of 106 operated patients with maxillo-facial deformity. Scand J Plast Reconstr Surg 12 (suppl 1): 1±68, 1974 Wolford LW: Eects of orthognathic surgery on nasal form and function in the cleft patient. Cleft Palate Craniofac J 29: 546±555, 1992
Arja HelioÈvaara Cleft Centre Department of Plastic Surgery Helsinki University Central Hospital Topeliuksenkatu 5 FI 00260 Helsinki Finland Tel: 358 9 471 87247 Fax: 358 9 471 87654 Paper received 6 July 1999 Accepted 7 February 2000