Article Outline
Summary
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Background
As muscles converge or intermingle around the perioral area, and it change by the sequential therapy for cleft lip and palate (CLP) infants. The force of perioral muscles has a great influence on maxillary development and morphology. Perioral force in CLP infants has not been well studied, and accurate and reliable measurement of perioral force in infants remains a challenge. The aim of this study was to investigate a new way to accurately and reliably measure perioral force in UCLP infants and explore the change before and after cheiloplasty.
Study design
A perioral force measurement system was developed and applied to measure perioral force at labial frenum area as well as the commissures on both the normal and the cleft sides of 4 infants with unilateral CLP before and after cheiloplasty. The results were analyzed using SPSS 19.0 software.
Results
The perioral force measurement system appears to produce valid results in infants with UCLP.Before cheiloplasty, perioral force of labial frenum area was 1.79±0.94 g/cm2, that of commissure on the normal side and cleft side was 5.41±1.01 g/cm2 and 3.12±1.55 g/cm2, respectively (P<0.05). After cheiloplasty, perioral force of labial frenum area was 12.73±3.51 g/cm2, that of commissure on the normal side and cleft side was 7.64±1.64 g/cm2 and 7.27±1.89 g/cm2, respectively (P>0.05).
Keywords:
Infant, Cleft lip and palate, Perioral force, Cheiloplasty, OrbicularisIntroduction
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Unilateral cleft lip and palate (UCLP), representing the most common form of congenital maxillofacial malformations worldwide1, is marked by abnormal perioral forces and affected by multiple clinical protocols. Perioral forces from soft tissues (lip, cheek, tongue,.etc.) keep changing and exert influence on the development of UCLP tissues2. Hence, according to the clinical guidelines recommended by the American Cleft-Palate-Craniofacial Association (ACPCA), pre-surgical nasoalveolar molding (PNAM) is suggested to be performed for UCLP infants after birth as early as possible. Literatures have proved that PNAM could improve both oral morphology and function of UCLP. However, the long term effect of PNAM is still controversial. Some clinical reports showed that PNAM was relevant to the constrictive maxillary arch during adolescent growth period of UCLP. The imbalance of muscular forces may lead to acquired dento-maxillofacial deformities as result. So far no report about the perioral forces of infancy cleft has been present3, and it's still in the shadow that what the power numbers of perioral forces are before and after PNAM therapeutic interventions.
Nevertheless, present researches are mainly focused on mixed and permanent dentition malocclusion of CLP patients with developed maxillofacial deformities. Bardach. J et al.4 showed that lip pressure after cheiolplasty could lead to secondary maxillofacial deformities such as backward movement and shortened length of maxillary in animals. However, some scholars believed that cheiolplasty had no.
significant impact on maxillary development. Therefore, it is of great significance to study how cheiolplasty influences maxillary development by affecting perioral force. To our best knowledge, this issue has not been explored so far. In this study, we established a method to measure perioral force in unilateral cleft of lip and palat (UCLP) infants and explored the relationship between perioral force and maxillary development before and after cheiloplasty.
Patients and methods
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Fabrication of perioral force measurement system
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
The system has three components, namely metal cantilever sensor, perioral force tester and computer analysis software. The sensor is "L" shaped with size of 4 mm wide, 15 mm long and 3 mm thick and has two measurement ranges of 0∼20 g/cm2 and 0∼100 g/cm2 with precision of 0.1g/cm2. The perioral force tester consists of six subsections (Figure 1), namely 1) battery and power control (Figure 2), 2) single-chip microcomputer (SCM) data acquisition and processing module, 3) LCD display module, 4) A/D conversion module, 5) amplifying circuit (Figure 3) and 6) panel keyboard and internal keyboard. The single-chip microcomputer controls all functional operations of the instrument. The computer-aided analysis software was written in modular structure using Visual C++ programming based on Microsoft Windows software system. When the sensor is covered by the inside of the lip or.
Figure 1
Schematic diagram of perioral force measurement system.
Figure 2
Physical connection of power control module.
cheek, the perioral force is collected as electrical signal, which is amplified by the circuit, converted to digital signal by the conversion module, processed by SCM and eventually displayed on the screen using the analysis software.
Patients
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Four 3-month-old infants with UCLP were enrolled in the study and subjected to cheiloplasty with Millard technique by the same senior surgeon. The perioral force of each infant was measured before and 3 months after surgery.
Measurement of perioral force
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Cleft palate plate was made of photosensitive resin (the material was from Dreve, Germany) in the shape of a customized dental tray locally (Figure 4). The plate was inserted into the patient's mouth to mark the measurement sites on labial frenum as well as the commissures of both normal and cleft sides. Resins (5 mm x 5 mm) at the marked areas were removed. The sensor was adjusted repeatedly to fit the plate and fixed on the lingual side using a silicon rubber (3M, USA). The perioral force.
Figure 4
Palate guard plate and measurement points.
measurement was conducted for 60 seconds when the infant was asleep and repeated 3 times (Figure 5). The wave of perioral force was shown on the screen of a computer connected to the perioral force tester (Figure 6).
Figure 5
Oral test using perioral force measurement system.
Figure 6
The wave of the perioral force for 60 seconds.
Statistical analysis
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
All data are presented as the mean ± standard error of the mean and statistically analyzed using the Statistical Package for the Social Sciences software 19.0 (SPSS Inc., USA). Simple regression analysis was performed between measurements with the highest correlation coefficient. The differences were considered significant at P < 0.05.
Results
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Successful establishment of the perioral force measurement system
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
The perioral force measurement system was designed for UCLP infants and a stable muscle strength measurement wave was obtained.
Perioral force of UCLP infants
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Before cheiloplasty, the perioral force was 1.79±0.94 g/cm2 at labial frenum area and 5.41±1.01 g/cm2 and 3.12±1.55 g/cm2 at angle of the mouth area of normal and cleft sides, respectively. After cheiloplasty, the perioral force is 12.73±3.51 g/cm2 at labial frenum, and 7.64±1.64 g/cm2 and 7.27±1.89 g/cm2 at angle of the mouth area of normal and cleft sides, respectively (Table1). The statistic analyses showed a significant difference in the perioral force in angle of the mouth area of normal side and cleft side before cheiloplasty (P<0.05), but not after cheiloplasty (P>0.05) (Table 1).
| Number | Labial frenum area | Angulus oris area of normal side | Angulus oris area of cleft side | |||
|---|---|---|---|---|---|---|
| Before | After | Before | After | Before | After | |
| 1 | 2.29±0.61 | 14.91±1.83 | 6.05±1.37 | 6.62±1.58 | 4.31±1.33 | 6.00±1.10 |
| 2 | 1.62±0.36 | 9.20±0.76 | 6.18±0.87 | 6.18±0.55 | 4.51±0.93 | 5.73±1.09 |
| 3 | 0.55±0.09 | 10.32±1.28 | 3.98±0.23 | 7.92±0.87 | 1.31±0.15 | 7.50±0.84 |
| 4 | 2.71±0.50 | 16.47±2.16 | 5.41±1.27 | 9.84±0.31 | 2.34±0.51 | 9.86±1.85 |
| Total | 1.79±0.94 | 12.73±3.51 | 5.41±1.01a | 7.64±1.64b | 12±1.55 | 7.27±1.89 |
at=2.47 and P<0.05 between normal and cleft sides.
bt=0.29 and P>0.05 between normal and cleft sides.
Discussion
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
Previous studies on perioral force are mainly focused on the mixed and permanent dentition malocclusion. Due to different experimental methods or instruments, the results are quite different. Aya Hasegawa5measured perioral force using a hydraulic capillary infusion system and showed it is 1-8 g/cm2 in normal occlusal adults. K. Ueki6 examined the changes in lip pressure of skeletal Class III patients before and after orthognathic surgery using a sensor measurement instrument and found the.
maximum variance in lip pressure is greater than 100 g/cm2. However, these studies have limitations. First, patients were limited to adolescents and adults. Second, their measurement ranges and results varied greatly. Third, the sensors were cemented to patient's teeth for retention5, 6, 7, 8, 9, 10. Fourth, the traditional instruments had large volume, poor stability as well as low accuracy and efficiency. All of the above have limited their application in UCLP infants. In addition, oral cavity of UCLP infants has certain particularities such as maxillary and lip discontinuity, alveolar fissures, alar collapse, and mouth nasal cavity. In addition, their external nose, upper lip, maxillary teeth and other organs grow rapidly and are prone to the influences of series of clinical interventions. Therefore, how to design and measure perioral force in UCLP infants is a major challenge to decrease adverse impacts of clinical interventions. In this research, beryllium bronze was used to make the metal cantilever beam sensor. The material is stable and less prone to deformation. In addition, it can be repeatedly adjusted to fit the patients' mouths. For UCLP infants, the sensor is designed as "L" shaped with an aluminum adjustable plate at the end to fit each patient and achieve a good retention. In addition, as the sensor size has a great influence on the results, the effective measurement area of the sensor is set as a cylinder with diameter of 3 mm and height of 3 mm. According to the existing literature, the perioral force in adolescents and adults was about 10 g/cm2 at mandibular rest position and about 100 g/cm2at functional status with a variance about 5 g/cm2.5, 6, 7, 8, 9, 10 Therefore, the measurement range of the perioral force measurement system was designed as 0∼20 g/cm2 and 0∼100 g/cm2, respectively. Our preliminary results showed that the minimum variance was only 0.09 g/cm2 and the maximum was 2.16 g/cm2. Moreover, the dynamic changing of perioral force can be recorded in real time to generate a curve graph for further analysis using software.
As shown in our preliminary results, in UCLP infants, perioral force in the labial frenum area was 1.79±0.94 g/cm2 before cheiloplasty and recovered to 12.73±0.51 g/cm2 after the surgery, showing the greatest change among the three measurement areas. In addition, perioral force in the angelus oris area at the normal side differed significantly from that at the cleft side before surgery (P<0.05), but not after cheiloplasty (P>0.05). UCLP Infants are always accompanied with abnormal stomatognathic system, as manifested as dehiscence of upper lip, maxillary bone, and maxillary alveolar ridge, backward of the maxillary bone at the cleft side and forward extension of maxillary bone at the normal side due to movement of the attached muscles. Owing to discontinuity of oral sphincter caused by cleft, the facial deformities often concentrate at the nasal floor of the alveolar bone, causing asymmetric development and difference of perioral force. Cheiloplasty restores the continuity of oral sphincter, which is helpful to guide growth and development of muscles at both sides. Meanwhile, the soft tissue tension of labial frenum area especially at the scar area increases after surgery, thus greatly affecting perioral force.
The study indicates preliminarily that the self-designed perioral force measurement system could accurately measure the perioral force of UCLP infants with less variation. However, only four subjects and two time points have been included in present study due to the limitation of source and time. Well-conducted large studies are needed to further explore the accuracy and reliability of the perioral force measurement system. The characteristics of changes in perioral force and its effect on the development of the maxilla, nose and palate in UCLP infants remains unclear and also need to be studied in future.
Funding
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
The study is supported by the fund of Jiangsu Provincial Medical Talent, China.
Conflict of interest statement
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
None
Acknowledgements
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
We would like to express our sincere gratitude to the patients and their parents for participating in this study.
References
Jump to SectionIntroductionPatients and methods Fabrication of perioral force measurement system Patients Measurement of perioral force Statistical analysisResults Successful establishment of the perioral force measurement system Perioral force of UCLP infantsDiscussionFundingConflict of interest statementAcknowledgementsReferences
- Weingartner, J., Lotz, K., Fanghanel, J. et al. Induction and prevention of cleft lip, alveolus and palate and neural tube defects with special consideration of B vitamins and the methylation cycle. [J]. J Orofac Orthop. 2007; 68: 266–277
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