Art-3_Jamilian
ORTHODONTICS www.stomaeduj.com
CEPHALOMETRIC PARAMETERS IN CLEFT PALATE
Original Articles
PATIENTS WITH AND WITHOUT ORONASAL FISTULA
1a* 2b 1c 1d
Abdolreza Jamilian , Ludovica Nucci , Mohammadamin Narimani , Maziyar Farhadi ,
1e 3 4g
Mona Farahmand , Zinat Kamali , Alireza Darnahal
1Department of Orthodontics, Faculty of Dentistry, Cranio Maxillofacial Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
2Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
3Faculty of Nutrition and Food Technology, National Nutrition and Food Technology, Research Institute Shahid Beheshti, University of Medical Science,
Tehran, Iran
4Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI 48109 USA
a
DDS, PhD, Professor; e-mail: info@jamilian.net; ORCIDiD: https://orcid.org/ 0000-0002-8841-0447
b
DDS, PhD Student Orthodontic Program; e-mail: ludovica.nucci@virgilio.it; ORCIDiD: https://orcid.org/0000-0002-7174-7596
c
DDS, PhD, Professor; e-mail: info@dr-narimani.com; ORCIDiD: https://orcid.org/0000-0001-6684-3121
d
DDS; e-mail: maziyar.farhadi@yahoo.com; ORCIDiD: https://orcid.org/0000-0002-1912-8675
e
DDS; e-mail: mona.farahmand87@gmail.com; ORCIDiD: https://orcid.org/0000-0002-0992-0263
f
Deputy of Research &Technology; e-mail: Z.kamali@sbmu.ac.ir; ORCIDiD: https://orcid.org/0000-0003-1488-8971
6
DDS, Post Doctorate Student of Periodontics; e-mail: alirezadarnahal@gmail.com; ORCIDiD: https://orcid.org/0000-0001-9629-731X
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(4).art.3
Introduction Failure in the fusion of medial nasal processes and maxillary prominences would result in the
development of a cleft lip while failure in merging the palatal shelves would result in the development of a
cleft palate (CP). At present, patients with a cleft palate (CP) have often undergone corrective surgery before
1 year of age. However, an oronasal fistula (ONF) often remains in the palate after surgery.
Methodology In this historical cohort, 40 patients with CP, 6-10 years old, who had undergone corrective
surgery at 1 year of age were selected by targeted sampling and assigned to two groups with ONF (N=20)
and without ONF (n=20). The two groups were matched in terms of age and gender. All patients had an
intraoral photograph of the maxilla and a lateral cephalogram. Twenty-three cephalometric parameters were
measured prior to the orthodontic treatment and compared between the two groups using a t-test.
Results CP patients with ONF had significantly higher Y-axis, gonial angle, Go1, Go2, GoGn-SN, U1-SN, and
lower lip to E line compared with those without ONF (P<0.05). The Jarabak index was significantly lower in
the CP patients with ONF compared with those without it (P<0.05). The difference in other cephalometric
parameters was not significant between the two groups (P>0.05).
Conclusion Patients with ONF had significantly greater growth in the vertical dimension compared with
those without ONF. Yet, the difference in the anteroposterior dimension was not significant between the two
groups.
KEYWORDS
Orthodontics and Dento-Facial Orthopedics; Oronasal Fistula (ONF); Cleft Lip; Cleft Palate; Cephalometric
Parameters.
1. INTRODUCTION CP patients often experience restricted development
of craniofacial structures. Controversy exists regar-
Failure in the fusion of medial nasal processes ding the causes of growth limitation in these
and maxillary prominences would result in the patients. Some researchers [2] have attributed it
development of a cleft lip while failure in merging to the surgical repair while some other factors not
palatal shelves would result in the development of a related to the corrective surgery such as genetics
cleft palate (CP) [1]. At present, patients with a cleft (inherited trait), and adaptive changes due to the
palate (CP) often undergo corrective surgery before mechanical presence of the cleft. Growth limitations
1 year of age. However, a fistula often remains in the associated with CP may affect the growth pattern in
palate after surgery that causes complications for all three planes of vertical, sagittal and transverse
patients. [3-5].
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Jamilian A, Nucci L, Narimani M, Farhadi M, Farahmand M, Kamali Z, Darnahal A. Cephalometric parameters in cleft palate patients with and
without oronasal fistula. Stoma Edu J. 2021;8(4):247-252
Received: October 11, 2021; Revised: 06 November; Accepted: November 11, 2021; Published: November 15, 2021
*Corresponding author: Prof. Abdolreza Jamilian, DDS, PhD, Department of Orthodontics, Faculty of Dentistry, Cranio Maxillofacial Research Center,
Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
Tel.: +98-22052228; Fax: +98-2122052228; e-mail: info@jamilian.net
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
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Jamilian A, et al.
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Oronasal fistula (ONF) is among the most common Wits appraisal: The distance between AO line and BO line
Original Articles complications of corrective surgery in CP patients Facial angle: The angle at the intersection of Frankfurt
[6]. Its prevalence ranges from 4% to 35% following plane and N-Pog line
primary palatoplasty [7]. Nasal regurgitation and Y-axis: The angle at the intersection of SN line and N-Gn
speech problems (mainly hypernasality) are the main line
symptoms associated with ONF. The location and Gonial angle: The angle at the intersection of GO-Gn and
size of the fistula and its causes are highly variable. Go-Ar lines
Primarily, it occurs as the result of repair under tension. GO1: The angle at the intersection of Ar-Go line and
Postoperative infection may also be the cause [6]. Go-N line
The growth pattern of surgically-treated and untreated GO2: The angle at the intersection of Go-N line and
CP patients has been extensively studied [8-12]. Go-Me line
However, information about the effect of presence/ GoGn-Sn: The angle at the intersection of Go-Gn and SN
absence of ONP after surgery on the growth pattern line
is limited. Knowledge about the growth pattern of N-Me: The distance between N point and Me point
CP patients can significantly affect the functional (or posterior facial height)
and esthetic treatment outcomes [13]. Considering S-Go: The distance between S point with Go point
the effect of surgical repair of the cleft on the growth (or anterior facial height)
pattern of the jaw in CP patients and the gap of Jarabak index: The ratio of the anterior facial height to
information about the effect of the presence/absence the posterior facial height
of ONF after surgery on the growth pattern, this study Inclination angle: The angle at the intersection of N’ line
aimed to assess the cephalometric parameters of 6 to perpendicular to the palatal plane
10-year-olds with CP who had undergone corrective U1-SN: The angle of upper incisors relative to SN line
surgery at 1 year of age prior to orthodontic surgery U1-NA: The distance from upper incisors to NA line
in two groups with and without ONF. L1-mand.: The angle of lower incisors relative to the
mandibular plane
L1-NB: The distance between the lower incisors and NB
2. MATERIALS AND METHODS
line
Interincisal angle: The angle between the maxillary and
This historical cohort was conducted on 40 CP
mandibular incisors
patients, 6-10 years of age, (mean age of 8.25 years)
Nasolabial angle: The angle between the line tangent to
who had undergone corrective surgery at 1 year of
the nasal base and the line tangent to the upper lip
age and presented to a private office in Tehran. All
Upper lip to E-line: The distance between the upper lip to
patients had an intraoral photograph of the maxilla
the Pn-Pog’ or E-line
and a lateral cephalogram prior to their orthodontic
Lower lip to E-line: The distance between the lower lip to
treatment. The photographs and cephalograms had
Pn-Pog’ or E-line
been taken for treatment purposes not related to For higher accuracy, all the above-mentioned
this study. All images were obtained in the habitual parameters were measured twice by the same
centric occlusion, with teeth in contact, lips relaxed, examiner with a 2-week interval to ensure adequate
and head in natural position. The parents or legal intraobserver agreement. The intraclass correlation
guardians of all patients signed informed consent coefficient (ICC) was calculated for this purpose.
forms prior to their participation in the study. The The data were analyzed using SPSS version 22 (SPSS
study was approved by the ethics committee of Inc., IL, USA). The normal distribution of the data in each
School of Dentistry Islamic Azad University, Tehran, group was analyzed using the Kolmogorov-Smirnov
Iran (Number 22710201961064). test. The measured cephalometric parameters were
A total of 40 patients including 20 patients with compared between the two groups using the t-test in
ONF and 20 patients without ONF were selected case of the normal distribution of the data and Mann-
and enrolled using targeted sampling. The patients Whitney test in case of the non-normal distribution of
were matched in terms of age and gender in the two the data. The level of significance was set at 0.05.
groups and there were 11 males and 9 females in each
group with a mean age of 8.4±1 years in the no fistula
and 8.1±1 years in the fistula group. Figure 1 and 2
show the occlusal view of patients with and without
ONF respectively. Their lateral cephalograms were
traced manually and the following cephalometric
parameters were measured on their lateral
cephalograms:
SN-FH: The angle between the SN line and the Frankfurt
plane
SNA: The angle at the intersection of SN line and NA line
SNB: The angle at the intersection of SN line and NB line
ANB: The angle at the intersection of NA line and NB line Figure 1. Occlusal view with oronasal fistula.
248 Stoma Edu J. 2021;8(4): 247-252 pISSN 2360-2406; eISSN 2502-0285
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Original Articles
Table 2. Cephalometric parameters in the vertical dimension in CP
patients with and without ONF..
Cephalometric Absence Presence P value
parameters of ONF of ONF (t-test)
Y-axis 66.4±5.8 71.5±3.6 0.001
Gonial angle 125.3±6.9 131.9±6.4 0.003
Go1 53.2±6.3 55.55±4.8 0.04
Go2 72.15±4.9 76.85±6.2 0.012
Go-GN-SN 33.4±4.1 35.9±3.5 0.038
N-Me 113±12.6 118.7±9.6 0.116
Figure 4. Occlusal view without oronasal fistula. S-Go 67.95±7.3 71.15±9.1 0.228
Jarabak Index 63.15±6.2 59.5±4.2 0.035
3. RESULTS Inclination Angle 84.25±5 83.25±7.7 0.629
The ICC value indicated excellent intraobserver Table 3 presents the dental cephalometric parameters
agreement. The minimum ICC was 0.991 for the ANB in CP patients with and without ONF. The U1-SN in
while the maximum ICC was 1 for the facial angle, CP patients with ONF was significantly higher than
Wits appraisal, Inclination angle, U1-SN, L1-mand., that in the group without fistula (P<0.005).
interincisal angle, gonial angle, Jarabak index, and Table 3. Dental cephalometric parameters in CP patients with and
nasolabial angle. The mean angular measurement without ONF.
error was 0.5°±0.5° and the mean linear measurement Cephalometric Absence Presence P value
error was 0.5±0.5 mm. parameters of ONF of ONF (t-test)
Table 1 presents the cephalometric parameters in U1-Sn 99±14.3 74.2±17.5 0.001
the anteroposterior dimension in CP patients with U1-NA 5.05±2.6 5.80± 2.8 0.445
and without ONF. The t-test revealed no significant L1-Mand 90.85±8 89.4±8.7 0.289
difference between the two groups of CP patients
L1-NB 4.05±1.8 4.00±1.8 0.947
with and without ONF in any of the cephalometric
Interincisal 128.05±26.5 111.63±58.2 0.962
parameters in anteroposterior dimension (P>0.05).
Angle
Table 1. Cephalometric parameters in the anteroposterior dimension in
CP patients with and without ONF. Table 4 presents the soft tissue cephalometric
Cephalometric Absence Presence P value parameters in CP patients with and without ONF.
parameters of ONF of ONF (t-test) Among the soft tissue cephalometric parameters,
the lower lip to E-line was significantly larger in CP
SN-FH 8.5±2.4 10.6±3.7 0.081 patients with fistula (P<0.005).
SNA 78.75±3 77.5±2.5 0.23
Table 3. Soft tissue cephalometric parameters in CP patients with and
SNB 79.45±2.5 78.25±2.3 0.12 without ONF.
ANB 3.5±1.9 3.4±2.2 0.9 Cephalometric Absence Presence P value
Wits appraisal -1.5±3.8 -2±4.8 0.72 parameters of ONF of ONF (t-test)
Facial angle 80.75±3.3 78.85±7.8 0.32 Nasolabial Angle 100.45±18.3 96.2±16.6 0.446
Up-lip to E-line -3.25±3.4 -3.5±4.7 0.678
Table 2 presents the cephalometric parameters in the Low-lip to E-line -1.25±2.6 1.6±4.2 0.015
vertical dimension in CP patients with and without
ONF. The results of the t-test revealed that the Y-axis 4. DISCUSSION
was significantly greater in CP patients with ONF
This study aimed to assess the cephalometric
compared with those without ONF (P<0.05). Also, the parameters prior to orthodontic treatment of
mean size of gonial angle was significantly larger in 6-10-year-old CP patients who had undergone
CP patients with ONF compared with those without corrective surgery at 1 year of age in two groups
it (P<0.05). Go1 and Go2 in CP patients with ONF with and without ONF. The results showed that in the
were significantly greater than the corresponding anteroposterior dimension, no significant difference
values in patients without a fistula (P<0.05). The existed between the two groups. However, in
the vertical dimension, patients with ONF had
Go-GN-SN parameter was significantly greater in
significantly greater vertical growth. This stark
CP patients with ONF as well (P<0.05). The Jarabak difference in the vertical dimension may be due to
index was significantly lower in CP patients with ONF mouth breathing in children, causing a more vertical
compared with those without it (P<0.05). growth pattern in patients with ONF.
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Naqvi et al. [13] reported short maxillary height in between CLP patients and healthy controls in the
Original Articles unoperated patients with ONF. However, the patients mandible (body, ramus, gonial angle, and mandibular
had a vertical growth pattern in their study. Their plane angle). The difference between their findings
results were in agreement with our findings. With and ours in the anteroposterior dimension may be
regards to the anterior growth however the results due to the fact that they had a healthy control group.
were in contrast to ours, which may be due to the Racial differences and number of lost teeth can also
presence of a healthy control group in their study.
affect the results.
Moreover, our study evaluated patients with and
Yoshida et al. [18] evaluated the morphology of
without ONF who had undergone corrective surgery.
Patients with CP have a lower anteroposterior growth unoperated CLP patients using lateral cephalometry.
than healthy individuals [14,15]. They reported maxillary retrusion and a steeper
Xu et al, [8] in their case-control study on 106 mandible in CLP patients, and the tendency for
cephalograms of non-syndromic CP patients and 102 maxillary retrusion and a steeper mandible had a
healthy controls in three groups of samples reported direct correlation with age. They also reported the
shortened cranial base length and reduced bony absence of labial proclination of incisor teeth in
nasopharyngeal height in patients with unrepaired CLP patients. However, 3 patients with CP had labial
isolated CP. The patients also had short maxillary proclination of the incisor teeth. Controversy in the
depth and height, and a posteriorly positioned results can be due to the difference in age range of
maxilla. The width of the nasal cavity, maxilla the patients, the presence of a healthy control group
and orbit had increased and they had shortened and the fact that they evaluated unoperated patients.
mandibular length and height. Adults had normal The sample size, age range of patients, technique of
nasopharyngeal and mandibular morphology.
surgery, and racial and environmental characteristics
Nonetheless, they still had shortened cranial base
length and short maxillary depth and anterior may explain the controversy in the results of studies.
height. The width of the nasal cavity, maxilla and Tooth loss and its time can also affect the results.
orbit had increased in them. They concluded that the In general, the ONF presence is associated with
craniofacial growth and morphology in unrepaired a vertical growth pattern When diagnosing and
isolated CP patients is significantly affected by non- treating CP patients with ONF, orthodontists should
surgical factors. The same results were reported by recognize the facial growth pattern in order to reduce
Ye et al [8]. The difference between our results and undesirable instances of craniofacial development
theirs is due to the presence of a healthy control to the extent possible.
group in the aforementioned studies and the fact This study was somewhat limited by its sample size. In
that we evaluated patients who had undergone order to examine the efficacy of different corrective
corrective surgery while they studied unoperated surgical techniques and their timing on the cranial
patients. growth pattern of CP patients more conclusively,
In contrast to our study Costello et al. [16] reported
similar procedures with larger group of participants
that the maxillary growth was much lower in
unoperated patients while the posterior facial height are recommended.
was higher in operated patients. Liao and Mars
[14] evaluated 39 patients with CP over 17 years of 5. CONCLUSION
age in comparison with age- and gender-matched
controls. They reported that patients with unilateral CP patients with ONF experienced a significantly
cleft lip and palate (CLP) had shorter height of the greater growth in the vertical dimension compared
basal maxilla, shorter posterior length of the basal with those without ONF. However, no significant
maxilla, and less protruded basal maxilla at the difference was noted in the anteroposterior
zygomatic level, compared with the control group. dimension between the two groups.
They found a significant correlation between the
posterior height of the basal maxilla and size of the AUTHOR CONTRIBUTIONS
cleft maxillary segment [14]. The difference between AJ: study concept, data interpretation, writing and revising the
their results and ours may be due to the fact that report and final approval of the article. LN: study design, literature
they only evaluated the maxilla while we assessed review. MN: administration, data interpretation, recruitment,
the cranial growth pattern. statistical analysis. MAF: data gathering, data interpretation. MOF:
Capelozza et al. [17] evaluated the craniofacial critical revision and final approval of the article. ZK: statistical
morphology in CLP patients using lateral analysis and critical revision. AD: drafting, data interpretation,
cephalometry. They reported that CLP patients had critical revision and final approval of the article.
a smaller and more protruded maxilla. Also, the
anteroposterior facial height was much larger in CONFLICT OF INTEREST
CLP patients, and significant differences were noted There is no conflict of interest.
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Abdolreza JAMILIAN
DDS, PhD, Professor
Department of Orthodontics
Faculty of Dentistry
Cranio Maxillofacial Research Center
Islamic Azad University
CV Tehran, Iran
Professor Abdolreza Jamilian is a researcher and specialist in the field of Orthodontics. He received his D.D.S (1991), MSc
in Orthodontics (1998), and Fellowship of Orthognathic Surgery & Craniofacial Syndromes (2010) from the Shahid Beheshti
University in Tehran, Iran. He obtained his membership of the European Board of Orthodontics in 2013. Now he is professor at
the Islamic Azad University in Tehran. His practice is limited to orthodontics. He has lectured in several international congresses
and has been a consultant for various journals. He has published over 200 original, peer reviewed research and review articles,
15 book chapters and more than 300 scientific communications. He holds 3 patents in the United States Patent and Trademark
Office. Research interests: Class 3 malocclusion, Cleft lip and palate, Orthognathic surgery.
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Questions
Original Articles
1. What are the main symptoms associated with ONF?
qa. Hypernasality;
qb. Less growth in the vertical dimension;
qc. Maxillary protrusion;
qd. Mandibular retrusion.
2. According to this article, what is the difference between the growth patterns of
patients with fistula and patients without fistula?
qa. Greater growth in the anteroposterior dimension between the two groups;
qb. Less growth in the maxilla in patients with fistula compared with those without ONF;
qc. Greater growth in the vertical dimension in patient with fistula compared with those without ONF;
qd. No significant difference was noted between the two groups.
3. According to this article, at what age did patients with cleft palate perform surgery?
qa. At 6 years of age;
qb. At 10 years of age;
qc. Between 6 to 10 years of age;
qd. At 1 year of age.
4. According to this article, what causes a recurrence of a fistula after surgery?
qa. Genetic factors;
qb. Patient age at surgery;
qc. Patient gender;
qd. Penetration.
https://escdonline.eu/escd-winter-meeting/
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