Evaluation of Facial Esthetics in Rehabilitated Adults with Complete Unilateral Cleft Lip and Palate: A Comparison between Professionals with and without Experience in Oral Cleft Rehabilitation

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


Introduction
Cle lip and palate is the most common type of craniofacial anomalies [1]. Among the different types of cle, complete cle lip and palate (CLP) is the most severe manifestation. It affects the facial esthetics, the speech, and hearing function, contributing to psychosocial problems [2][3][4]. e global rehabilitation of individuals with CLP is extremely important for social inclusion and psychological health; therefore, one of the main goals of rehabilitation is reaching good facial esthetics and speech intelligibility.
As far as facial beauty is concerned, orthodontists and plastic surgeons have long searched for the appropriate achievement of facial esthetics in the rehabilitation of oral cles. Many features contribute to facial beauty such as maxillomandibular relation, facial proportions and symmetry, the skin aspect, the color of the eyes, and teeth shape and position, to mention just a few [5][6][7]. Besides the shape of the nose and lips, maxillary growth de�ciency also contributes to esthetic impairment in individuals with CLP [8][9][10]. e concept of beauty varies according to the observer's opinion, ethnicity, age, and cultural patterns suitable for a given population at a given time [11]. Additionally, professionals and laypersons may evaluate facial esthetics differently. Chetpakdeechit et al. [12] evaluated the facial esthetic of patients with complete bilateral cle lip and palate aer the orthodontic treatment, comparing professional and nonprofessional examiners. A web-based questionnaire with 12 photo sets was answered by 25 orthodontists and 20 young adults. ey had to address the �rst three unpleasant features in each photograph and classi�ed the facial esthetics as bad, good, fairly good, or excellent. e three features �rst noticed 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. e authors concluded that orthodontists were generally less critical than laypersons in their evaluations. One of the hypotheses of their study was that professionals related and not related to cle rehabilitation may assess facial esthetics differently.
e rehabilitation protocol for CLP varies among different centers. e World Health Organization recommends that the protocol for CLP rehabilitation be rational and efficient, containing only procedures with positive long term impact [13].e assessment of the �nal facial esthetics of patients with CLP contributes to the evaluation of the quality of treatment delivered in a single center. erefore, the aim of this study was to subjectively evaluate the pleasantness of the facial pro�le in rehabilitated adults with complete unilateral cle lip and palate. Additionally, this study aimed at comparing the facial assessment of professionals related and not related to cle rehabilitation.

Materials and Methods
is project was approved by the Ethical Committee at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRCA-USP) and informed consent was obtained. e study sample comprised 30 rehabilitated adults with unilateral complete cle lip and palate (UCLP), consecutively selected at the HRCA-USP. e inclusion criteria were: White-Brazilians, absence of syndromes, complete rehabilitation performed only at the HRCA-USP. e sample included males ( ) and females ( ) with a mean age of 24 years (range: 17.2 to 30.7 years). e cle was present more 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 protocol adopted by the institution which includes the lip repair with Millard technique at 3 to 6 months of age and the palate repair with Von Langenback technique at 12 months of age. e protocol also includes the secondary bone gra procedure at 10 to 11 years of age and orthognathic surgery at 18 years of age for cases classi�ed as �oslon 4 and 5. Secondary lip repair is performed around 7 years of age and the secondary rhinoplasty is performed with 14 years of age or aer the orthognatic surgery. Nine out of 30 patients of the sample were submitted to orthognathic surgery and the remaining 21 had only the orthodontic treatment. e photographs were taken using a standardized method. e patients were positioned standing in a cephalostat with the natural head position, in front of a white background. An umbrella type �ash with photocell [14] was placed 1.3 m from the cephalostat and 0.51 m above the ground. e distance between the light source and the cephalostat was 0.80 m. A Nikon Coolpix 995 digital camera was placed 0.87 centimeters away from the wall and its support for height adjustment ranged 1 : 02 to 2 : 18 meters.
Patients were instructed to have the teeth occluded and the lips relaxed. Images of the facial pro�le on the right and le side were performed for each patient. e images obtained were transferred to a Hewlett Packard model Brio/Intel Pentium II MMX 300 MHz with 64 MB of RAM and printed with a 10 × 15 cm size. e photographs were evaluated by twenty-�ve examiners divided into 5 groups: 5 orthodontists with experience in the rehabilitation of oral cles (ODC), 5 orthodontists with no experience in the cle treatment (ONC), 5 plastic surgeons with experience in oral cle (PSDC), 5 plastic surgeons 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 at HRCA-USP.
In order to evaluate the facial pro�le, each examiner received a photo album with the sample of 60 photographs. �acial pro�les photographs of each patient were positioned in a same page for simultaneous visualization. No identi�cation of the side of the cle was provided. e raters were instructed to perform the assessment within approximately 30 seconds for each photograph, assigning a score from 1 to 9 according to 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 was requested to identify the facial structures responsible for the unpleasant aspect. e photographs were evaluated twice by the 25 examiners, with an interval of 30 days between both evaluations. : the Wilcoxon test statistic; : normal distribution of probabilities. ODC: orthodontists dealing with cle; ONC: orthodontists with no experience cle; PSDC: plastic surgeons dealing with cle; PSNC: plastic surgeons with no experience on cle; L: laymen.

Data Analysis
e mean, median, and quartiles of the scores were calculated for each patient. e Wilcoxon Test was used for comparing the evaluation of the cle and noncle sides. Kendall Coefficient of Concordance was used to evaluate the interexaminer agreement. Friedman test and Student-Newman-Keuls Test for multiple comparisons were used for evaluating differences between the categories of examiners. e signi�cance level regarded was 5%.

Results
Tables 1 and 2 show the interobserver agreement for the cle side and noncle side, respectively. Kendall coefficients of concordance ( ) varied from 0.47 to 0.75 and showed a statistically signi�cant agreement. Figures 1 and 2 show the scores for facial esthetics obtained for each category of examiners, respectively, for the cle side and noncle side pro�le. Orthodontists and plastic surgeons with experience in oral cles assigned the highest scores for facial esthetics compared to the other examiners. Table 3 shows the comparison between the cle and noncle sides for the �rst evaluation. No difference between the scores of the cle and noncle sides was observed for all the 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).    ere was a statistical signi�cant di�erence between the categories of examiners for the evaluation of facial esthetics (Friedman test, 2 = 96, 13; = , ). 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 cles. Figure 3 shows the classi�cation of facial esthetics for the sample according to Reis et al. [15], for each category of examiners. �sthetically acceptable pro�le was the most prevalent classi�cation in the sample for all the category of examiners, with the exception of orthodontists with experience in cle rehabilitation, who considered the pro�le esthetically pleasant for the majority of the patients. e midface and nose were frequently cited as the facial structure responsible for the esthetically unpleasant pro�les (Figure 4).

Discussion
e concept of beauty is very subjective and varies individually. e evaluation of facial esthetics varies depending on the examiner [11]. When evaluating the facial esthetics of patients with cle lip and palate, besides the �eld of the professional, the experience in cle rehabilitation also might have an in�uence. Despite being a subjective evaluation process, there was an agreement among the examiners regarding the concept of beauty in the �rst and second evaluation in this study.
e results showed a similar esthetic evaluation of the facial pro�le of the cle and noncle sides (Table 3). Although the cle was unilateral, the facial esthetics at the end of the rehabilitation is similar on both sides of the face. With the exception of the laypersons, most of the examiners have not capture differences between the sides with and without cle. On the other hand, laypersons have scored the cle and noncle side differently. Maybe that's the most important opinion because it re�ects the way in which society evaluates the rehabilitation of patients with cle. Actually, the facial structure commonly cited as responsible for unpleasant pro�les was the midface (Figure 4). e maxillary de�ciency is commonly observed in patients with unilateral complete cle lip and palate and is apparent on both sides of the face [16,17]. Regarding the cephalometric aspect, the maxilla is smaller and presents a clockwise rotation. Although not as dramatically as the maxilla, the mandible is also smaller, with its base and ramus decreased, increased gonial angle and posterior displacement. e pro�le can become straight or concave during the growth phase. Maxillary sagittal de�ciency in�uences the nasolabial angle, the nasal apex, and the zygomatic projection. During the evaluation of the facial pro�le, the maxillary de�ciency seems to overcome the presence of the lip scar. Laypersons were the only category of examiners who assigned statistically different scores for the cle and noncle sides. Laypersons were sensitive to the presence of the cle attributing lower scores to the cle side pro�le.
e professionals experienced in the rehabilitation of cle lip and palate had an in�uence on the evaluation of the �nal facial esthetics. Orthodontists and plastic surgeons dealing with cle lip and palate assigned the highest scores for the pro�le esthetics (means of 7.5 and 6.0, resp.; Figures  1 and 2). Laypersons assigned an intermediary score (mean of 5.0). e lowest scores were assigned by orthodontists and plastic surgeons without experience in the rehabilitation of oral cles, who assigned a mean score of 4.0. Professionals dealing with the rehabilitation of CLP are aware of the limitations of the treatment. is explains the higher scores attributed by CLP professionals when evaluating the �nal facial esthetics. Interestingly, plastic surgeons of the hospital (PSDC) were more demanding in their assessment than the hospital orthodontists (Figures 1 and 2). e possible explanation is that the orthodontists follow facial growth and are more familiar with the midface de�ciency. e orthodontists with experience in CLP, particularly, were more lenient with the esthetic judgment. In a study of the satisfaction of professionals with the treatment results of patients with CLP [18], plastic surgeons had a lesser frequency (39%) of satisfaction when compared to orthodontists (58.5%). In our study, Orthodontists and plastic surgeons without experience in cle rehabilitation were equally more strict than laypersons in their appreciation of facial esthetics. ese professionals were persuing perfection at the end of rehabilitation of patients with CLP.
�hen considering the classi�cation of Reis et al. [15], most of the sample was classi�ed as esthetically acceptable for most of the examiners including laypersons and professionals with no experience in the rehabilitation of CLP (Figures 3 and  5). e orthodontists dealing with CLP were the only group of examiners who classi�ed most of the sample as esthetically pleasant (Figures 3 and 6) for the reasons previously discussed, while one third of the sample was classi�ed as esthetically unpleasant for professional not related to CLP ( Figure 7). Laypersons evaluated the pro�les as esthetically unpleasant only in 20% of the sample. On the other hand, professionals related to CLP did not evaluate any pro�le as unpleasant (Figure 3). In comparison with a study with noncle patients [15], the facial esthetics of 100 young adults without orthodontic treatment was classi�ed as esthetically unpleasant, esthetically acceptable, and esthetically pleasant in 8%, 89%, and 3% of the sample, respectively.
Laypersons assessment may correspond to the society view of our rehabilitated patients with CLP. e majority of the sample was evaluated as esthetically acceptable (73.3%) for laypersons (Figure 3). Patients with complete unilateral cle lip and palate rehabilitated within the contemporary possibilities, including alveolar bone gra and orthognathic surgery, still show a distinct facial pro�le morphology compared to noncle individuals. e orthodontist related to CLP seems to be aware of these differences in their evaluation of esthetics.
It is important to highlight that beauty is in�uenced by numerous subjective factors such as color and texture of the skin, the thickness of the upper and lower lips, morphology and color of the eyes and hair style [5,6]. ese features completely independent of the presence of the cle and at the same time might have an in�uence in the assessment of beauty of individuals with CLP. Different facial structures were cited as responsible for the esthetically unpleasant pro�les including midface, nose, and chin ( Figure 4). ese �ndings suggest that maxillary and chin advancement with the orthognatic surgery would be highly desirable procedures in patients with moderate�severe maxillary de�ciency and mandibular retrusion. Additionally, secondary rhinoplasty would be a very important procedure in the esthetical point of view.
Future studies should also consider the evaluation of esthetics in the facial frontal view. Additionally, the evaluation of facial esthetics should be conduct in patients with rehabilitated complete bilateral cle lip and palate.

Conclusion
e facial pro�les of rehabilitated adults with UCLP were classi�ed mostly as esthetically acceptable, with variations among the categories of examiners. e examiners dealing with oral cles classi�ed the facials esthetics with higher scores compared to professional without experience in oral cles and layperson, probably, due to their knowledge of the limitations involved in the rehabilitation process.