Universidade de São Paulo

2013

Evaluation of facial esthetics in rehabilitated

adults with complete unilateral cleft lip and

palate ISRN Plastic Surgery, New York, v. 2013, p. 357568, 2013http://www.producao.usp.br/handle/BDPI/33339

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Hindawi Publishing CorporationISRN Plastic SurgeryVolume 2013, Article ID 357568, 7 pageshttp://dx.doi.org/10.5402/2013/357568

Clinical StudyEvaluation of Facial Esthetics in Rehabilitated Adults withComplete Unilateral Cleft Lip and Palate:A Comparison between Professionals with and withoutExperience in Oral Cleft Rehabilitation

Araci Malagodi Almeida,1 Leopoldino Capelozza Filho,2 Flavio Mauro Ferrari Junior,3

Rita de Cassia Moura Carvalho Lauris,1 and Daniela Gamba Garib4

1 Department of Orthodontics, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC/USP),Bauru, SP, Brazil

2 Universidade do Sagrado Coração, Bauru, SP, Brazil3 Private Practice, Bauru, SP, Brazil4Hospital for Rehabilitation of Craniofacial Anomalies (HRAC/USP) and Bauru Dental School, University of São Paulo,Bauru, SP, Brazil

Correspondence should be addressed to Araci Malagodi Almeida; amalagodi@yahoo.com.br

Received 14 October 2012; Accepted 30 October 2012

Academic Editors: A. S. Halim, Z. Panthaki, and D. D. Park

Copyright © 2013 Araci Malagodi Almeida et al. is is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Objectives. e aim of this study was to evaluate the facial esthetics of White-Brazilian adults with complete unilateral cle lip andpalate (UCLP) rehabilitated at a single center. Design. 30 patients (13 females; 17 males; mean age of 24.0 years), rehabilitated at asingle center, were photographed and evaluated by 25 examiners, 5 orthodontists, and 5 plastic surgeons dealing with oral cles, 5orthodontists and 5 plastic surgeons with no experience in the cle treatment, and 5 laymen.eir facial pro�les were classi�ed intoesthetically unpleasant, esthetically acceptable, and esthetically pleasant.Results. Orthodontists dealing with oral cles classi�ed themajority of the sample as esthetically pleasant. Plastic surgeons dealing with oral cle, orthodontists, and plastic surgeons withoutexperience with oral cles classi�ed most of the sample as esthetically acceptable. Laymen evaluation also considered the majorityof the sample as esthetically acceptable. Conclusions. e facial pro�les of rehabilitated adults with UCLP were classi�ed mostlyas esthetically acceptable, with variations among the categories of examiners. e examiners dealing with oral cles gave higherscores to the facial esthetics when compared to professionals without experience in oral cles and laypersons, probably due to theirknowledge of the limitations involved in the rehabilitation process.

1. Introduction

Cle lip and palate is the most common type of craniofacialanomalies [1]. Among the different types of cle, completecle lip and palate (CLP) is the most severe manifestation. Itaffects the facial esthetics, the speech, and hearing function,contributing to psychosocial problems [2–4]. e globalrehabilitation of individuals with CLP is extremely importantfor social inclusion and psychological health; therefore, oneof the main goals of rehabilitation is reaching good facialesthetics and speech intelligibility.

As far as facial beauty is concerned, orthodontists andplastic surgeons have long searched for the appropriateachievement of facial esthetics in the rehabilitation of oralcles. Many features contribute to facial beauty such as max-illomandibular relation, facial proportions and symmetry,the skin aspect, the color of the eyes, and teeth shape andposition, to mention just a few [5–7]. Besides the shape of thenose and lips, maxillary growth de�ciency also contributesto esthetic impairment in individuals with CLP [8–10]. econcept of beauty varies according to the observer’s opinion,ethnicity, age, and cultural patterns suitable for a given

2 ISRN Plastic Surgery

population at a given time [11]. Additionally, professionalsand laypersons may evaluate facial esthetics differently.Chetpakdeechit et al. [12] evaluated the facial esthetic ofpatients with complete bilateral cle lip and palate aerthe orthodontic treatment, comparing professional and non-professional examiners. A web-based questionnaire with 12photo sets was answered by 25 orthodontists and 20 youngadults. ey had to address the �rst three unpleasant featuresin each photograph and classi�ed the facial esthetics asbad, good, fairly good, or excellent. e three features �rstnoticed by the orthodontists were: the upper lip, the nose,and the scar, while the young adults reported the teeth,the upper lip, and occlusion/alignment of the teeth. eauthors concluded that orthodontists were generally lesscritical than laypersons in their evaluations. One of thehypotheses of their study was that professionals related andnot related to cle rehabilitation may assess facial estheticsdifferently.

e rehabilitation protocol for CLP varies among dif-ferent centers. e World Health Organization recommendsthat the protocol for CLP rehabilitation be rational andefficient, containing only procedures with positive long termimpact [13].e assessment of the �nal facial esthetics ofpatients with CLP contributes to the evaluation of thequality of treatment delivered in a single center. ere-fore, the aim of this study was to subjectively evaluatethe pleasantness of the facial pro�le in rehabilitated adultswith complete unilateral cle lip and palate. Additionally,this study aimed at comparing the facial assessment ofprofessionals related and not related to cle rehabilita-tion.

2. Materials andMethods

is project was approved by the Ethical Committee atthe Hospital for Rehabilitation of Craniofacial Anomalies,University of São Paulo (HRCA-USP) and informed consentwas obtained. e study sample comprised 30 rehabilitatedadults with unilateral complete cle lip and palate (UCLP),consecutively selected at the HRCA-USP.e inclusion crite-ria were: White-Brazilians, absence of syndromes, completerehabilitation performed only at the HRCA-USP.e sampleincluded males (𝑛𝑛 𝑛 𝑛𝑛) and females (𝑛𝑛 𝑛 𝑛𝑛) with a meanage of 24 years (range: 17.2 to 30.7 years).e clewas presentmore commonly in the le side, with a proportion of 3 : 1.

All patients were operated by the plastic surgeon team,composed of 12 surgeons, following the current protocoladopted by the institution which includes the lip repair withMillard technique at 3 to 6months of age and the palate repairwith Von Langenback technique at 12 months of age. eprotocol also includes the secondary bone gra procedure at10 to 11 years of age and orthognathic surgery at 18 yearsof age for cases classi�ed as �oslon 4 and 5. Secondary liprepair is performed around 7 years of age and the secondaryrhinoplasty is performed with 14 years of age or aer theorthognatic surgery. Nine out of 30 patients of the samplewere submitted to orthognathic surgery and the remaining21 had only the orthodontic treatment.

T 1: Kendall’s coefficient of concordance (𝑊𝑊) of the judges inthe evaluation of photographs of the cle side.

Category 𝑊𝑊 𝑃𝑃ODC 0,75 0,000∗

ONC 0,74 0,000∗

PSDC 0,55 0,000∗

PSNC 0,70 0,000∗

L 0,63 0,000∗∗Statistically signi�cant correlation (𝑃𝑃 𝑃 𝑃𝑃𝑃𝑃); ODC: orthodontists dealingwith cle; ONC: orthodontists with no experience cle; PSDC: plasticsurgeons dealing with cle; PSNC: plastic surgeons with no experience oncle; L: laymen.

e photographs were taken using a standardizedmethod. e patients were positioned standing in a cephalo-stat with the natural head position, in front of a whitebackground. An umbrella type �ash with photocell [14]was placed 1.3m from the cephalostat and 0.51m abovethe ground. e distance between the light source and thecephalostat was 0.80m. A Nikon Coolpix 995 digital camerawas placed 0.87 centimeters away from the wall and itssupport for height adjustment ranged 1 : 02 to 2 : 18 meters.

Patients were instructed to have the teeth occludedand the lips relaxed. Images of the facial pro�le on theright and le side were performed for each patient. eimages obtainedwere transferred to aHewlett PackardmodelBrio/Intel Pentium II MMX 300MHz with 64MB of RAMand printed with a 10 × 15 cm size.

e photographs were evaluated by twenty-�ve examin-ers divided into 5 groups: 5 orthodontists with experiencein the rehabilitation of oral cles (ODC), 5 orthodontistswith no experience in the cle treatment (ONC), 5 plasticsurgeons with experience in oral cle (PSDC), 5 plasticsurgeons with no experience in cle (PSNC) and 5 laymen(1 veterinarian, 1 engineer, two lawyers and 1 agronomist).All the professionals with experience in oral cle worked atHRCA-USP.

In order to evaluate the facial pro�le, each examinerreceived a photo album with the sample of 60 photographs.�acial pro�les photographs of each patient were positioned ina same page for simultaneous visualization. No identi�cationof the side of the clewas provided.e raterswere instructedto perform the assessment within approximately 30 secondsfor each photograph, assigning a score from 1 to 9 accordingto Reis et al. [15].

Esthetically unpleasant pro�le�scores 1, 2, and 3

Esthetically acceptable pro�le�scores 4, 5, and 6

Esthetically pleasant pro�le�scores 7, 8, and 9

When the score assigned was 1 to 3, the examiner wasrequested to identify the facial structures responsible for theunpleasant aspect. e photographs were evaluated twice bythe 25 examiners, with an interval of 30 days between bothevaluations.

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T 2: Kendall’s coefficient of concordance (𝑊𝑊) of the judges forthe evaluation of the photographs of noncle side.

Category 𝑊𝑊 𝑃𝑃ODC 0,74 0,000∗

ONC 0,67 0,000∗

PSDC 0,47 0,000∗

PSNC 0,70 0,000∗

L 0,61 0,000∗∗Statistically signi�cant concordance (𝑃𝑃 𝑃 𝑃𝑃𝑃𝑃); ODC: orthodontists deal-ing with cle; ONC: orthodontists with no experience cle; PSDC: plasticsurgeons dealing with cle; PSNC: plastic surgeons with no experience oncle; L: laymen.

T 3: Comparison between the evaluation of the cle andnoncle sides (Wilcoxon test).

Category 𝑇𝑇 𝑍𝑍 𝑃𝑃ODC 13,5 0,630 0,529 nsONC 3,5 1,468 0,142 nsPSDC 23,0 1,572 0,116 nsPSNC 23,0 0,000 1,000 nsL 19,5 2,508 0,012∗∗Statistically signi�cant difference (𝑃𝑃 𝑃 𝑃𝑃𝑃𝑃); Ns: no statistically signi�cantdifference.𝑇𝑇: the Wilcoxon test statistic; 𝑍𝑍: normal distribution of probabilities.ODC: orthodontists dealing with cle; ONC: orthodontists with no experi-ence cle; PSDC: plastic surgeons dealing with cle; PSNC: plastic surgeonswith no experience on cle; L: laymen.

3. Data Analysis

emean,median, and quartiles of the scores were calculatedfor each patient. e Wilcoxon Test was used for comparingthe evaluation of the cle and noncle sides. Kendall Coeffi-cient of Concordance was used to evaluate the interexamineragreement. Friedman test and Student-Newman-Keuls Testformultiple comparisonswere used for evaluating differencesbetween the categories of examiners. e signi�cance levelregarded was 5%.

4. Results

Tables 1 and 2 show the interobserver agreement for the cleside and noncle side, respectively. Kendall coefficients ofconcordance (𝑊𝑊) varied from 0.47 to 0.75 and showed astatistically signi�cant agreement.

Figures 1 and 2 show the scores for facial estheticsobtained for each category of examiners, respectively, for thecle side and noncle side pro�le. Orthodontists and plasticsurgeons with experience in oral cles assigned the highestscores for facial esthetics compared to the other examiners.

Table 3 shows the comparison between the cle andnoncle sides for the �rst evaluation. No difference betweenthe scores of the cle and noncle sides was observed for allthe categories of examiners, with the exception of laypersons.Laypersons gave a slightly worse score for the cle side (mean= 4.9) compared to noncle side (mean = 5.3).

1

2

3

4

5

6

7

8

9

10

ODC ONC PSDC PSNC L

Sco

re

F 1: �ean, �rst quartile, third quartile, minimum, andmaximum of the scores for each category of raters, in the cle sidepro�le. (ODC: orthodontists dealing with cle; ONC: orthodontistswith no experience cle; PSDC: plastic surgeons dealing with cle;PSNC plastic surgeons with no experience on cle; L: laymen.).

1

2

3

4

5

6

7

8

9

10

ODC ONC PSDC PSNC L

Sco

re

F 2: �ean, �rst quartile, third quartile, minimum, and max-imum of the scores for each category of raters, in the noncle sidepro�le. (ODC: orthodontists dealing with cle; ONC: orthodontistswith no experience cle; PSDC: plastic surgeons dealing with cle;PSNC plastic surgeons with no experience on cle; L: laymen.).

(%)

0

10

20

30

40

50

60

70

80

Unpleasant

Acceptable

Pleasant

ODC ONC PSDC PSNC L

F 3: Distribution of the classi�cation of facial esthetics for thesample for each category of raters.

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0 5 10 15 20 25 30 35 40 45 50

MouthSkin

Upper third faceLong face

Nasolabial angleConcave profile

Convex profileChin neck line

Upper lipLower third face

Lower lip

Straight profile

ChinNose

Midface

1 (0.6%)1 (0.6%)1 (0.6%)1 (0.6%)

2 (1.2%)3 (1.7%)3 (1.7%)

5 (2.9%)

6 (3.5%)7(4.1%)8 (4.7%)

9 (5.3%)16 (9.4%)

29 (17%)

31 (18.2%)47 (27.6%)

Maxillomandibular

Frequency (n)

F 4: Facial structures cited by raters as responsible for the esthetically unpleasant pro�les.

(a) (b) (c)

(d) (e) (f) (g)

F 5: Patient considered esthetically acceptable. (a), (b), and (c) Before the primary surgeries; (d) and (e) before orthodontic treatment;(f) and (g) at the end of the rehabilitation.

ere was a statistical signi�cant di�erence between thecategories of examiners for the evaluation of facial esthetics(Friedman test, 𝜒𝜒2 = 96, 13; 𝑃𝑃 = 𝑃, 𝑃𝑃𝑃). e Student-Newman-�euls test for multiple comparisons identi�ed sig-ni�cant di�erences between all the categories of examiners,except for the plastic surgeons (PSNC) and orthodontists(ONC) with no experience with oral cles.

Figure 3 shows the classi�cation of facial esthetics forthe sample according to Reis et al. [15], for each categoryof examiners. �sthetically acceptable pro�le was the mostprevalent classi�cation in the sample for all the categoryof examiners, with the exception of orthodontists withexperience in cle rehabilitation, who considered the pro�leesthetically pleasant for the majority of the patients.

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(a) (b) (c)

(d) (e) (f) (g)

F 6: Patient considered esthetically pleasant. (a), (b) and (c) Before the primary surgeries; (d) and (e) before orthodontic treatment; (f)and (g) at the end of the rehabilitation.

e midface and nose were frequently cited as the facialstructure responsible for the esthetically unpleasant pro�les(Figure 4).

5. Discussion

e concept of beauty is very subjective and varies indi-vidually. e evaluation of facial esthetics varies dependingon the examiner [11]. When evaluating the facial estheticsof patients with cle lip and palate, besides the �eld of theprofessional, the experience in cle rehabilitation also mighthave an in�uence. Despite being a subjective evaluation pro-cess, there was an agreement among the examiners regardingthe concept of beauty in the �rst and second evaluation in thisstudy.

e results showed a similar esthetic evaluation of thefacial pro�le of the cle andnoncle sides (Table 3). Althoughthe cle was unilateral, the facial esthetics at the end ofthe rehabilitation is similar on both sides of the face. Withthe exception of the laypersons, most of the examinershave not capture differences between the sides with andwithout cle. On the other hand, laypersons have scoredthe cle and noncle side differently. Maybe that’s the mostimportant opinion because it re�ects theway inwhich societyevaluates the rehabilitation of patients with cle. Actually, thefacial structure commonly cited as responsible for unpleasantpro�les was the midface (Figure 4). e maxillary de�ciency

is commonly observed in patients with unilateral completecle lip and palate and is apparent on both sides of the face[16, 17]. Regarding the cephalometric aspect, the maxillais smaller and presents a clockwise rotation. Although notas dramatically as the maxilla, the mandible is also smaller,with its base and ramus decreased, increased gonial angleand posterior displacement. e pro�le can become straightor concave during the growth phase. Maxillary sagittalde�ciency in�uences the nasolabial angle, the nasal apex,and the zygomatic projection. During the evaluation of thefacial pro�le, the maxillary de�ciency seems to overcome thepresence of the lip scar. Laypersons were the only categoryof examiners who assigned statistically different scores forthe cle and noncle sides. Laypersons were sensitive to thepresence of the cle attributing lower scores to the cle sidepro�le.

e professionals experienced in the rehabilitation ofcle lip and palate had an in�uence on the evaluation ofthe �nal facial esthetics. Orthodontists and plastic surgeonsdealing with cle lip and palate assigned the highest scoresfor the pro�le esthetics (means of 7.5 and 6.0, resp.; Figures1 and 2). Laypersons assigned an intermediary score (meanof 5.0). e lowest scores were assigned by orthodontists andplastic surgeons without experience in the rehabilitation oforal cles, who assigned a mean score of 4.0. Professionalsdealing with the rehabilitation of CLP are aware of thelimitations of the treatment. is explains the higher scores

6 ISRN Plastic Surgery

(a) (b) (c)

(d) (e) (f) (g)

F 7: Patient considered esthetically unpleasant. (a), (b) and (c) Before the primary surgeries; (d) and (e) before orthodontic treatment;(f) and (g) at the end of the rehabilitation.

attributed by CLP professionals when evaluating the �nalfacial esthetics.

Interestingly, plastic surgeons of the hospital (PSDC)were more demanding in their assessment than the hospitalorthodontists (Figures 1 and 2). e possible explanationis that the orthodontists follow facial growth and are morefamiliar with the midface de�ciency. e orthodontists withexperience in CLP, particularly, were more lenient with theesthetic judgment. In a study of the satisfaction of profes-sionals with the treatment results of patients with CLP [18],plastic surgeons had a lesser frequency (39%) of satisfactionwhen compared to orthodontists (58.5%). In our study,Orthodontists and plastic surgeons without experience incle rehabilitationwere equallymore strict than laypersons intheir appreciation of facial esthetics.ese professionals werepersuing perfection at the end of rehabilitation of patientswith CLP.

�hen considering the classi�cation of Reis et al. [15],most of the sample was classi�ed as esthetically acceptable formost of the examiners including laypersons and professionalswith no experience in the rehabilitation of CLP (Figures 3 and5). e orthodontists dealing with CLP were the only groupof examiners who classi�ed most of the sample as estheti-cally pleasant (Figures 3 and 6) for the reasons previouslydiscussed, while one third of the sample was classi�ed asesthetically unpleasant for professional not related to CLP

(Figure 7). Laypersons evaluated the pro�les as estheticallyunpleasant only in 20% of the sample. On the other hand,professionals related to CLP did not evaluate any pro�leas unpleasant (Figure 3). In comparison with a study withnoncle patients [15], the facial esthetics of 100 young adultswithout orthodontic treatment was classi�ed as estheticallyunpleasant, esthetically acceptable, and esthetically pleasantin 8%, 89%, and 3% of the sample, respectively.

Laypersons assessment may correspond to the societyview of our rehabilitated patients with CLP. e majority ofthe sample was evaluated as esthetically acceptable (73.3%)for laypersons (Figure 3). Patients with complete unilateralcle lip and palate rehabilitated within the contemporarypossibilities, including alveolar bone gra and orthognathicsurgery, still show a distinct facial pro�le morphology com-pared to noncle individuals.eorthodontist related toCLPseems to be aware of these differences in their evaluation ofesthetics.

It is important to highlight that beauty is in�uenced bynumerous subjective factors such as color and texture of theskin, the thickness of the upper and lower lips, morphologyand color of the eyes and hair style [5, 6]. ese featurescompletely independent of the presence of the cle and atthe same time might have an in�uence in the assessment ofbeauty of individuals with CLP. Different facial structureswere cited as responsible for the esthetically unpleasant

ISRN Plastic Surgery 7

pro�les including midface, nose, and chin (Figure 4). ese�ndings suggest that maxillary and chin advancement withthe orthognatic surgery would be highly desirable proceduresin patients with moderate�severe maxillary de�ciency andmandibular retrusion. Additionally, secondary rhinoplastywould be a very important procedure in the esthetical pointof view.

Future studies should also consider the evaluation ofesthetics in the facial frontal view. Additionally, the evalu-ation of facial esthetics should be conduct in patients withrehabilitated complete bilateral cle lip and palate.

6. Conclusion

e facial pro�les of rehabilitated adults with UCLP wereclassi�ed mostly as esthetically acceptable, with variationsamong the categories of examiners. e examiners dealingwith oral cles classi�ed the facials esthetics with higherscores compared to professional without experience in oralcles and layperson, probably, due to their knowledge of thelimitations involved in the rehabilitation process.

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