Facial growth of adults with unoperated clefts Pradip R. Shetye, BDS, MDS, MOrthRCS a,b, * a Department of Orthodontics, KLES Institute of Dental Sciences, Belgaum, Karnataka, 590010, India b Institute of Reconstructive Plastic Surgery, New York University Medical Center, 560 First Avenue, New York, NY 10016, USA Abnormal growth and development of the cranio- facial structures in patients treated for cleft lip and palate deformity is a familiar finding. The major abnormalities are observed in the maxilla, which is the primary bone affected by the cleft. In 2001, Williams et al [1] studied 218 patients treated for unilateral cleft lip and palate and reported that 70% of these patients at 12 years of age had midface retrusion [1]. She stated that over 40% of the patients had severe midfacial hypoplasia and would eventu- ally need orthognathic surgery to correct the skeletal discrepancy. In 1987, Ross [2] compared 538 lateral cephalograms collected from 15 centers around the world and concluded that inhibition of anterior growth and translation of the maxilla was a common finding. The distribution of the treated cleft patients illustrates that patients with abnormal midfacial growth are concentrated in the center of the bell curve, whereas patients with good growth and severe growth deficiency are dispersed on either side of the curve [3]. Clinically treated cleft patients with growth ab- normalities normally present with a concave facial profile, midface deficiency, and a class III skeletal relationship [4]. The maxilla is deficient in the an- teroposterior and the transverse and vertical dimen- sions. Dentally there is lingual inclination of the maxillary incisors contributing to the anterior cross- bite. The posterior dental segments are also col- lapsed and constricted, leading to posterior dental or skeletal crossbites. The extent of this abnormal growth of the midface varies from mild to severe. Management of patients with midface hypoplasia normally requires extensive and long-term orthodon- tic treatment. Patients start orthodontic treatment in early mixed dentition at approximately 6 years of age and are followed until adulthood. Palatal expan- sion is often necessary to correct the posterior cross- bite, and protraction headgear is used to treat the midface hypoplasia. In some patients with severe skeletal dysplasia, surgical intervention is necessary to correct midface retrusion. The surgical proce- dure is a midface distraction in early childhood or a LeFort I osteotomy for midface advancement after the completion of growth. Understanding the primary etiologic factors result- ing in abnormal maxillary growth enables us to plan our treatment properly, minimize the orthodontic treatment time, and reduce major secondary correc- tive surgeries. The etiology of midface deficiency can be attributed to three major factors: (1) the intrinsic deficiency secondary to the cleft itself, (2) the growth inhibition as a result of corrective surgery performed to repair the lip and palate during early childhood, and (3) the genetic endowment for midface growth in- herited from both parents. Examination of untreated cleft patients can elucidate the genetically determined component of craniofacial growth from disturbances caused by surgical intervention. It is essential to recognize the differences in craniofacial growth be- tween the unoperated and operated individual be- cause this can improve our understanding of the effects of the surgical repair of the lip or palate and the orthodontic management of these cases. In developed countries, most patients with cleft lip and palate undergo surgery early in life, which eliminates the opportunity to observe and study large 0094-1298/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0094-1298(03)00137-8 * Institute of Reconstructive Plastic Surgery, New York University Medical Center, 560 First Avenue, New York, NY 10016. E-mail address: pradipshetye@hotmail.com Clin Plastic Surg 31 (2004) 361 – 371