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Ultrasound examination of upper lip in patients with unilateral cheilognathopalatoschisis
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Vokhidov Utkirbek Nuridinovich, Tashkent State Stomatological Institute, Department of children's maxillofacial surgery E-mail: dr_utkirbek@mail.ru
Ultrasound examination of upper lip in patients with unilateral cheilognathopalatoschisis
Abstract: Congenital cheilognathopalatoschisis is one of the most actual and urgent problems of the stomatology. 205 patients were under supervision, 122 of them were the patients with unilateral bilateral cleft of the lip and palate, 83 of them suffered from unilateral isolated cleft lip. The research showed that the echographic examination which allows a detailed image of the upper lip, alveolar process, hard and soft palate, palatal suture and tongue is highly efficient method of assessment of individual anatomical peculiarities of the building of the upper jaw in children with cheilognathopalatoschisis.
Keywords: congenital cheilognathopalatoschisis, echographic study, children, labioplasty.
The enhancement in the sphere of medical rehabilitation of children with congenital cheilognathopalatoschisis is one of the most actual and urgent problems of the present day. Complete medical, psychological, social adaptation of a child and the formation of the personality depend on the results of elimination of anatomical, functional and cosmetic defects as well as timely conduction of rehabilitation works [1; 4].
In order to provide qualified assistance to this group of difficult patients multi-stage surgery and constant supervision of surgeons, orthodontists, pediatricians, speech therapists and other specialists are required from the birth till an adult age at the specialized centers [2].
Detailed knowledge of individual anatomical peculiarities of children with congenital cheilognathopalatoschisis allows the surgeon to choose the appropriate operative method. Underestimation of the degree of anatomical defect in the patients with congenital cheilognathopalatoschisis hinders the achievement of good post operative results.
Traditionally to examine these type patients ray diagnostics such as radiography, computer tomography, magnetic resonance tomography are used in addition to physical methods. However the usage of ray diagnostics may be maximally limited in patients of an early age. Moreover, in order to examine infants and children of a preschool age, it is important to ensure immobility of them, which requires the condiction of the examination under anesthesia.
Ultrasound examination has become widely used in the practice of maxillofacial surgery in the recent years. The competency of ultrasound is spreading not only on the study of soft tissues of face and neck, which is the traditional variant of using this method, but also it allows to evaluate bone structures-the surface of the bone, its configuration, the degree of mineralization as well as relative positioning of bone fragments. Absolute advantages of this method are its non-invasiveness, safety and the opportunity of using it on patients for many times [5-7].
Ultrasound-based diagnostic imaging can be carried out at a different position of the patient (standing, sitting, lying), which is particularly important in the assessment of functional condition of soft tissues. This method may be applied to the patients of any age including newborns and it does not require special preparation and assistive means.
Informativeness of echographic study gives an opportunity to limit the use of radiological methods, to use invasive diagnostic intervention less frequently, to approach to the usage of expensive examinations as CT and MRI more rationally [3].
Study objective
To improve the quality of examination of patients with congenital cheilognathopalatoschisis on the basis of introduction of improved methods of echographic study to the diagnostic process.
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Section 8. Medical science
Materials and methods
The study was conducted at the department of “Children’s maxillofacial surgery” and the department of “Visualization and functional diagnostics” of the clinic of Tashkent Medical Academy. 205 patients were under supervision, 122 of them were the patients with unilateral bilateral cleft of the lip and palate, 83 of them suffered from unilateral isolated cleft lip. The age range of the patients was from 6 months to 3 years. In order to study the normal anatomy of orbicular muscle of mouth 50 healthy children of the same age range who formed a control group were studied.
Echographic study was conducted with the ultrasound scanner Sonoline — Sienna (“Siemens”, Germany). A multifrequency linear transducer 5.0-7.5-9.0 MHz with the length of the radiating surface of 35 mm. and convex probe with a frequency of 2.6-3.5-5.0 MHz were used in the study. The sections were obtained in the frontal, horizontal and sagittal planes. The visualization was carried out on the display of the monitor of the ultrasound device in grey scale (B-mode) in real time. More informative echographic images were registered on thermopaper. Echographic imaging was performed when the patient was in horizontal position: the child was lying on the on the couch, face up with a slightly upturned head. All studies were performed through percutaneous access.
Echographic examination of orbicular muscle of mouth was carried out in horizontal plane with linear sensor with a frequency of 5.0-7.5-9.0 MHz. Diagnostic beam was focused in the near field at a depth of 0.5-1.5 cm. During the study the orbicular muscle of mouthand the tissues surrounding it were visualized at the condition of rest. Echographic study of the upper lip was carried out on 50 healthy children and on 205 patients with cleft lip and palate until the primary labioplasty and a year after it. The labioplasty was performed on the patients according to Obukhov-Tennyson, Milliard and according to Azimov-Vokhidov modification. The width of cleft lip, basal ridge and the orbicular muscle of mouth were determined in the patients who were not operated on. In patients with cheilognathopalatoschisis the width of the muscle on healthy and operated side, the width of the orbicular muscle of mouth and the degree of fibrous tissue replacement were determined; the width of postoperative scar and relative positioning of contiguous parts of the muscle (their diastasis and separation in depth) was discovered; the distance between lateral fragments of basal ridge, the height of lateral fragments of basal ridge was studied; the width of the cleft and its upper (at the level of apical basis) and lower (at the level of alveolar ridge) parts, the length of the cleft (from the edge of the pyriform aperture to the top of the alveolar process) and the width of upper jaw in the upper and lower part of the cleft were measured; the state of the subcutaneous fat cellular tissue and submucosa was assessed.
The results of the study
Echographic study of the upper lip was performed on two groups of children. The first group consisted of 205 patients and 122 of them suffered from unilateral bilateral
cheilognathopalatoschisis, 83 of them had unilateral isolated cleft lip before and after primary labioplasty. Their age range was from 6 months to 3 years. The second group (control group) consisted of 50 healthy children from 6 months till the age of 3. Echographic study of the upper lip in both of the group allowed to obtain an image of dermis, the orbicular muscle of mouth, submucosa, to evaluate the thickness, symmetry echogenicity of each layer.
Normally in echogramms the upper lip had a stratified structure; the skin, the orbicular muscle of mouth, submucosa and mucosa. The dermis was well developed and its thickness was 3.4 ± 0.4 mm. In 22 children (44 %) we observed the decrease of the dermis thickness in the area of grooved phil-trum to 2.78 ± 0.32mm. The thickness of the orbicular muscle of mouth in the projection of philtrum was 1.2 ± 0.07 mm. In the lateral sections of the upper lip the thickness of the muscle layer was more and it significantly varied, which is explained by the attachment of several mimic muscles to the the orbicular muscle of mouth (m. levatorangulioris, m. levatorlabiisuperioris, m. risorius, m. zygomaticusmajor, m. zygomaticus minor). The thickness of the submucosal layer was 1.85 ± 0.18 mm. The layers of the right and left halves of the upper lip were symmetrical in all children.
In patients with the cleft lip before the labioscopy the width of the cleft (the distance between the fragments of the upper lip) and the width of the orbicular muscle of mouth were measured. The width of the cleft lip was 4.48 ± 2.6 mm., the width of the orbicular muscle of mouth was 12.5 ± 4.8 mm.
In patients with unilateral bilateral cheilognathopala-toschisis the distance between processus alveolaris was studied before and after primary labioscopy. For this we divided this group into three subgroups according to the degree of the cleft.
As a result of the examination of the patients we obtained the first group of 16 patients with the first degree cleft according to Frolov. The distance between processus alveolaris was 4.85 ± 0.7 mm. The second group of 52 patients had the second degree cleft according to Frolov. The distance between processus alveolaris was10.2 ± 0.54 mm. The third group of 54 patients had the third degree cleft according to Frolov. The distance between processus alveolaris was16.2 ± 0.8 mm. Echographic examination after a year after labioplasty showed a sudden decrease in the distance between alveoli. This distance was 1.07 ± 0.6 mm. in the patients of the first group, in the second group the distance between alveoli was 4.65 ± 0.83 mm., in the third group it was 6.05 ± 0.30 mm.
The state of soft tissues of the upper lip was eavaluated after the labioscopy: the thickness of the orbicular muscle of mouth was determined on the healthy and the side operated on earlier, the degree of its substitution with fibrous tissue was studied, the width of the postoperative scar was measured, mutual positioning of bilateral sections of the muscle, their diastasis and depth were analyzed. The thickness and the state of dermis and submucosa on the operated side were also examined.
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Ultrasound examination of upper lip in patients with unilateral cheilognathopalatoschisis
In the patients with scar deformations of the lip the thickness of all layers of the upper lip was less than in children of the control group. The fact that drew our attention in 122 patients with unilateral cleft of the lip after the primary labioscopy was the assymmetry of all layers of the upper lip and the peculiarities of the orbicular muscle of the mouth: the thickness of the orbicular muscle on operated side was 0.72 ± 0.14 mm. which was less than in norm. In 83 patients with isolated cleft of the lip after the primary labioscopy the thickness of the orbicular muscle of the mouth on the healthy side was 0.9 ± 0.2 mm., and on the operated side it was 0.7 ± 0.58 mm.
Echographic study allowed to measure the width of the scar on the skin and on the orbicular muscle as well as to evaluate its maturity. The width of the scar was from 1.3 mm. to 5.3 mm. (3.15 mm. on avarage). Echographic examination allowed to clarify the direction of the muscle fibers and muscle attachment points, as well as the mutual arrangement of adjacent sections of the orbicular muscle: their diastasis and separation in depth. In 83 (68 %) patients with unilateral cheilognathopalatoschisis the fragments of the muscle were compared, in 39 (32 %) of them they were located under one angle to each other.
Echographic study allowed getting an image and visualising the surface of the lateral fragments of processus alveolaris of the upper jaw. In 122 children the defect of processus alveolaris was observed. In patients with isolated cleft lip no deformation of processus alveolaris was found.
These findings gave an opportunity to orient in the quantity of bone chips required for eliminating the defect of the alveolar process and reduce the size of the donor wound.
Discussion of the results
In patients with scar deformation the echographic study enabled the evaluation of the condition of all layers of the upper lip after labioplasty: to determine the thickness of the orbicular muscle of the mouth, the dermis and submucosa on the healthy and earlier operated side, the degree of substitution of the muscle with the scar tissue; mutual location
of the muscle fibers, to measure the thickness of the scar and to assess its maturity.
Ultrasound examination allowed visualisation of the surface of alveolar process. Echographically the cleft of the alveolar process looks like a defect of the bone tissue of various width. Echographic study gave opportunity to conduct linear measurements of the cleft parametres. Ultrasound study allowed determining the width of the cleft, the edge of the piriform aperture and in the crest of the alveolar process. These measurements can be used for determining the degree of underdevelopment of the alveolar process of the upper jaw in the area of the cleft (Pershina M. A., 2001).
The information obtained is very actual, as it is difficult to do X-ray examination at this age.In the case of thinning or osteoporosis of the outer cortical bone it is possible to visualize the beginnings of permanent teeth in the cleft area.
Conclusion:
1. Echographic examination which allows a detailed image of the upper lip, alveolar process, hard and soft palate, palatal suture and tongue is highly efficient method of assessment of individual anatomical peculiarities of the building of the upper jaw in children with cheilognathopalatoschisis.
2. Echographic examination gives an opportunity to analyze the condition of the upper lip after labioplasty, to determine the thickness of the orbicular muscle of the mouth, dermis and submucosa on the healthy and previously operated side, the degree of substitution of the muscle with the scar tissue; mutual location of the muscle fibers, to measure the thickness of the scar and to assess its maturity.
3. Echographic examination allows to evaluate morphological parameters of the cleft of the alveolar process; the width of the cleft and its upper (at the level of apical basis) and lower (at the level of alveolar ridge) parts, the length of the cleft (from the edge of the pyriform aperture to the top of the alveolar process) and the thickness of the upper jaw in the upper and lower part of the cleft.
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