Dental Arch Width in Unoperated Cleft Patients Latief, Benny S.
Citation
Latief, B. S. (2005, January 20). Dental Arch Width in Unoperated Cleft Patients. Retrieved from https://hdl.handle.net/1887/649
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Chapter 3
Summary
This chapter is dealing with the study of dental arch width of the mandible in four types of unoperated clefts. Earlier studies on cleft patients mainly focussed on the transversal dimensions of the maxilla. Only a few reports can be found in the literature that have investigated the mandibular width of cleft patients, although it is well-known that compensatory dental and skeletal changes can occur in one jaw as a result of changes in the other one. The aim of this study has been to investigate whether the mandibular dental arch width of unoperated adult cleft patients differs from adult non-cleft individuals of the same population. The material consisted of dental casts of adult unoperated cleft patients divided into 4 groups: UCLA (n=168), UCLP (n=68), BCLA (n=18), and BCLP (n=13). Dental casts of 24 non-cleft individuals from the same population were available as a control group.
Chapter 3
3.1 Introduction
Surprisingly, up until now, studies on cleft patients have focused mainly on the transversal dimensions of the maxilla only (Bishara, 1992; Da Silva Filho et al, 1992b, 1997). Only a few reports can be found in the literature that investigated the mandibular width of cleft patients, although it is well-known that compensatory dental and skeletal changes can occur in one jaw as a result of changes in the other. When the mandible was included in earlier published studies, these studies mainly focused on the skeletal development of the mandible and therefore were conducted on head films.
From the literature, concerning cephalometric studies on adults who were operated at adult age, one may conclude that the shape of the mandible is often different from the non-cleft individuals (Da Silva Filho et al, 1992a, 1993, 1998). In a mixed sample of patients with cleft lip and alveolus, cleft lip, alveolus and palate, and isolated cleft palate patients Da Silva Filho et al (1993) found that the mandibular configuration was significantly different compared to the non-cleft sample. In all cleft groups the mandible displayed a shorter ramus and body length and there was no difference among the three cleft types, as far as the configuration of the mandible was concerned.
Most studies on mandibular morphology in cleft lip and palate patients were performed on early operated patients and not on completely untreated individuals. In a sample of 26 early operated adult patients, with bilateral complete cleft lip and palate, Smahel (1984) described changes of the mandibular shape while the mandible was also more retrognatic and posteriorly rotated in bilateral clefts. Han et al (1995) studied mandibular morphology through lateral and frontal head films in a sample of 57 early operated patients with UCLA, UCLP and CP. The linear measurements of the mandible did not differ from those in cleft subjects. But a larger intercondylar width, a larger gonial angle and a slightly retruded mandible in UCLP and CP patients suggest that the total width of the mandible is increased especially in the molar area. The authors considered these findings as compensative changes of the mandible related to the changes of the naso-maxillary complex rather than the result of an intrinsic developmental impairment of the mandible.
performed on dental casts of adult cleft patients, who were operated in early childhood. Polaczek (1992) evaluated 61 early operated UCLP patients at 17 - 20 years of age, treated surgically in childhood. Moreover these patients had undergone orthodontic treatment for 6½ years in order to correct the malocclusion. He found that the mandibular intercanine width was increased (although not statistically significant) in the cleft patients compared to the non-cleft patients. At the level of the first molar, the intermolar width was significantly increased in the cleft group compared to the non-cleft population. Heidbüchel and Kuijpers-Jagtman (1997) analyzed a sample of 22 BCLP patients, operated between 3 and 17 years of age. Two third of these patients had undergone orthodontic treatment previously. They found a narrower intercanine width in the mandible while the intermolar width was comparable to the non-cleft controls. Nystrom et al (1992) conducted a study on a sample of 60 patients with isolated cleft palate. In their study intercanine and intermolar width at the level of the first molars of both the upper and the lower jaw was smaller in cleft patients compared to the control group. As this group contained only young children until 6 years of age, it is difficult to draw conclusions about the intermolar width when mandibular growth has ceased.
In conclusion it may be stated that little information is available on transversal dimensions of the mandible of patients with clefts. And even when transversal measurements were performed, only intermolar width and intercanine width are reported. Finally, the measurements are invariably performed on patients that were treated surgically in childhood. Moreover, these patients have often undergone orthodontic treatment after the initial operations and therefore it is impossible to separate the influence of the cleft itself on the mandibular width from this of the orthodontic treatment.
Chapter 3
3.2 Materials and methods
Transversal mandibular arch dimensions of patients with unoperated clefts were measured on dental casts. The distribution of the unoperated cleft sample according to cleft type and age is given in table 2.1.
The control group consisted of 24 randomly selected non-cleft individuals from the surrounding population (see table 2.3 and 2.4). The dental casts were digitized according to the protocol as described in chapter 2. For every molar, 2 points were recorded: the tip of the distobuccal cusp and the tip of the mesiobuccal cusp. In the case of abrasion, the centre of the abraded cusp was used as a reference point. For the premolars and the canines, the tip of the buccal cusps was recorded. Between corresponding points, at the right and left side, the following distances were calculated:
371 - 471 distance between distal cusps of the right and left second molar 372 - 472 distance between mesial cusps of the right and left second molar 361 - 461 distance between distal cusps of the right and left first molar 362 - 462 distance between mesial cusps of the right and left first molar 351 - 451 distance between buccal cusps of the right and left second
premolar
341 - 441 distance between buccal cusps of the right and left first premolar 331 - 431 distance between cusps of the right and left canine.
The lower arch ratio (%) was calculated as 331-331 distance / 361-461 distance * 100.
Means and standard deviations were calculated for all variables. Occasionally models in the cleft groups were missing or teeth were extracted. Therefore the numbers differ per variable. The t-test was conducted to determine whether the mean values of the cleft groups showed significant differences from each other and from the control group. The level of significance was set at p<0.05.
3.3 Results
Means and sd (in mm) for mandibular arch width for the adult unoperated UCLA, UCLP and the control group are summarized in table 3.1. Box-whisker plots of these measurements are shown in figure 3.1.
Table 3.1 Mean and SD (in mm) of transversal mandibular dental arch dimensions for
unoperated UCLA and UCLP and the non-cleft controls. For explanation of the variables see Materials and methods section.
GROUP N MEAN SD GROUP N MEAN SD DIFF S.E t-VALUE p-VALUE
331-431 distance UCLA 167 28.0 2.6 Control 24 27.5 1.6 0.5 0.4 1.23 .21 UCLP 62 27.5 2.7 Control 24 27.5 1.6 0 0.5 -0.04 .96 UCLA 167 28.0 2.6 UCLP 62 27.5 2.7 0.5 0.4 1.26 .20 341-441 distance UCLA 168 35.9 2.5 Control 24 35.6 1.7 0.4 0.4 0.89 .37 UCLP 62 35.6 2.9 Control 24 35.6 1.7 0 0.5 0.03 .97 UCLA 168 35.9 2.5 UCLP 62 35.6 2.9 0.3 0.4 0.82 .41 351-451 distance UCLA 159 41.2 2.8 Control 24 40.1 2.1 1.1 0.5 2.28 .02 UCLP 60 41.7 2.9 Control 24 40.1 2.1 1.5 0.6 2.71 .007 UCLA 159 41.2 2.8 UCLP 60 41.7 2.9 -0.4 0.4 -1.00 .31 362-462 distance UCLA 145 47.3 2.7 Control 24 46.2 2.5 1.1 0.6 2.00 .04 UCLP 45 47.5 2.8 Control 24 46.2 2.5 1.3 0.7 2.04 .04 UCLA 145 47.3 2.7 UCLP 45 47.5 2.8 -0.2 0.5 -0.47 .63 361-461 distance UCLA 145 50.6 3.0 Control 24 49.8 2.6 0.8 0.6 1.33 .18 UCLP 45 51.3 2.7 Control 24 49.8 2.6 1.5 0.7 2.29 .02 UCLA 145 50.6 3.0 UCLP 45 51.3 2.7 -0.7 0.5 -1.56 .11 372-472 distance UCLA 151 52.1 3.1 Control 24 51.4 2.4 0.7 0.5 1.33 .18 UCLP 55 53.3 2.9 Control 24 51.4 2.4 1.9 0.6 3.05 .003 UCLA 151 52.1 3.1 UCLP 55 53.3 2.9 -1.2 0.5 -2.54 .01 371-471 distance UCLA 145 54.5 3.3 Control 24 53.8 2.5 0.7 0.6 1.19 .23 UCLP 51 56.5 3.0 Control 24 53.8 2.5 2.6 0.7 3.97 .0002 UCLA 145 54.5 3.3 UCLP 51 56.5 3.0 -1.9 0.5 -3.87 .0003
LOWER ARCH RATIO
UCLA 144 55.1 5.2 Control 24 55.3 4.0 -0.1 0.9 -0.16 .87 UCLP 45 53.8 4.6 Control 24 55.3 4.0 -1.5 1.1 -1.39 .16 UCLA 144 55.1 5.2 UCLP 45 53.8 4.6 1.3 0.8 1.65 .10
DIFF = difference in arch width between UCLA, UCLP and control and between UCLA
and UCLP
S.E = standard error of the difference
Chapter 3
At the level of the second premolars and the mesial cusps of the first molar, the mandibular dimensions are significantly wider in both cleft groups than in the control group. Although not statistically significant all mandibular arch dimensions in UCLA patients seem to be wider than in the control group. In UCLP subjects mandibular arch width is significantly wider compared to the control group from the mandibular second molar up to the second premolar. At the level of the first premolar and the canine, there are no significant differences between the cleft and the control group. At the level of the distobuccal cusp of the second molars, the intermolar distance is 2.6 mm wider than in the control group. This difference is roughly decreasing. At the level of the second premolar the mandibular width of the UCLP patients is only 1.5 mm wider than in the control group.
24 24 24 24 24 24 24 55 45 45 60 62 62 51 151 145 145 159 168 167 145 N = Reference points 3-b 4-b 5-b 6-mb 6-db 7-mb 7-db Width mandible (mm) 70 60 50 40 30 20 10 GROUP UCLA UCLP control
igure 3.1 Box-whisker plot of transversal mandibular dental arch dimensions (in mm)
61 distance; 6-mb = 362-462 distance; 5-b = 351-451 distance; 4-b = 341-441 distance; 3-b = 331-431 distance.
F
of the unoperated UCLA and UCLP subjects, and the control group. 7-db = 371-471 distance; 7-mb = 372-472 distance; 6-db = 361-4
Table 3.2 Mean and SD (in mm) of transversal mandibular dental arch dimensions for
the unoperated BCLA and BCLP groups and for the non-cleft control group. For explanation of the variables see Materials and methods section.
GROUP N MEAN SD GROUP N MEAN SD DIFF S.E t-VALUE p-VALUE
31-431 distance CLP 13 28.3 2.8 ontrol 24 27.5 1.6 0.8 0.8 0.98 .32 3.0 BCLP 13 28.3 2.8 -0.1 1.0 -0.06 .95 CLP 12 35.2 3.4 ontrol 24 35.6 1.7 -0.4 1.1 -0.36 .72 2.7 BCLP 12 35.2 3.4 1.1 1.2 0.97 .33 CLP 10 41.1 2.6 ontrol 24 40.1 2.1 1.0 0.9 1.07 .28 3.1 BCLP 10 41.1 2.6 0.5 1.1 0.46 .64 3.1 CLP 9 45.0 3.1 2.8 1.3 2.16 .03 CLP 9 48.3 2.8 ontrol 24 49.8 2.6 -1.6 1.1 -1.47 .14 2.8 BCLP 9 48.3 2.8 2.4 1.2 2.10 .04 d 2 2 2.8 CLP 12 52.1 2.8 0 1.1 0.04 .96 CLP 12 55.2 2.7 ontrol 24 53.8 2.5 1.3 0.9 1.41 .15 2.9 BCLP 12 55.2 2.7 -0.6 1.1 -0.53 .59 R CLP 9 56.8 5.8 ontrol 24 55.3 4.0 1.5 2.1 0.73 .46 BCLP 9 56.8 5.8 -0.6 2.1 -0.28 .78 3 BCLA 18 28.3 3.0 Control 24 27.5 1.6 0.8 0.8 0.99 .32 B C BCLA 18 28.3 341-441 distance BCLA 18 36.3 2.7 Control 24 35.6 1.7 0.8 0.7 1.05 .29 B C BCLA 18 36.3 351-451 distance BCLA 16 41.6 3.1 Control 24 40.1 2.1 1.5 0.9 1.69 .09 B C BCLA 16 41.6 362-462 distance BCLA CLP 15 9 47.8 45.0 3.1 3.1 Controlontrol 2424 46.246.2 2.52.5 1.61.2 0.91.1 -1.07 1.68 .09.28 B C B BCLA 15 47.8 1di 361-46 stance BCLA 16 50.7 2.8 Control 24 49.8 2.6 0.9 0.9 1.00 .31 B C BCLA 16 50.7 372-472 istance BCLA CLP 16 12 52.1 52.1 2.8 2.8 Controlontrol 44 51.451.4 2.42.4 0.70.7 0.90.9 0.86 0.74 .38.45 B C B BCLA 16 52.1 1 371-47 distance BCLA 16 54.6 2.9 Control 24 53.8 2.5 0.7 0.9 0.83 .40 B C BCLA 16 54.6
LOWE ARCH RATIO
BCLA 16 56.2 3.6 Control 24 55.3 4.0 0.9 1.2 0.76 .44
B C
BCLA 16 56.2 3.6
DIFF = ch tw n LP
and BCLP
.E = standard error of difference
difference in ar width be ee BCLA, BC and control and between BCLA
S
Chapter 3 24 24 24 24 24 24 24 12 9 9 10 12 13 12 16 16 15 16 18 18 16 N =
Reference points
3-b 4-b 5-b 6-mb 6-db 7-mb 7-dbWidth mandible (mm)
70 60 50 40 30 20 10GROUP
BCLA BCLP controlThe results for the mandibular arch width of unoperated adult BCLA and BCLP subjects are summarized in table 3.2 and the box-whisker plots are shown in figure 3.2. In both groups there were no statistically significant differences between the cleft groups and the non-cleft group concerning the mandibular transversal dimensions.
Figure 3.2 Box-whisker plot of transversal mandibular dental arch dimensions (in mm)
of the unoperated BCLA and BCLP groups and the control group.
7-db = 371-471 distance; 7-mb = 372-472 distance; 6-db = 361-461 distance; 6-mb = 362-462 distance; 5-b = 351-451 distance; 4-b = 341-441 distance; 3-b = 331-431 distance.
Table 3.3 shows the comparison of the transversal arch dimensions between unilateral and bilateral clefts: between UCLA and BCLA and between UCLP and BCLP. There are hardly any differences between the groups. Only the intermolar distance between the first molar is significantly wider in UCLP than in BCLP.
Table 3.3 Comparison of the transversal mandibular dental arch dimensions (mean
and SD in mm) of the unoperated UCLA and BCLA, and UCLP and BCLP groups. For explanation of the variables see Materials and methods section.
GROUP N MEAN SD GROUP N MEAN SD DIFF S.E t-VALUE p-VALUE
331-431 distance UCLA 167 28.0 2.6 BCLA 18 28.3 3.0 -0.3 0.7 -0.38 .70 ULCP 62 27.5 2.7 BCLP 13 28.3 2.8 -0.8 0.8 -1.00 .31 341-441 distance UCLA 168 35.9 2.5 BCLA 18 36.3 2.7 -0.4 0.7 -0.62 .53 ULCP 62 35.6 2.9 BCLP 12 35.2 3.4 0.4 1.1 0.37 .71 351-451 distance UCLA 159 41.2 2.8 BCLA 16 41.6 3.1 -0.4 0.8 -0.50 .61 ULCP 60 41.7 2.9 BCLP 10 41.1 2.6 0.6 0.9 0.61 .54 362-462 distance UCLA 145 47.3 2.7 BCLA 15 47.8 3.1 -0.5 0.8 -0.56 .57 ULCP 45 47.5 2.8 BCLP 9 45.0 3.1 2.6 1.1 2.31 .02 361-461 distance UCLA 145 50.6 3.0 BCLA 16 50.7 2.8 -0.1 0.7 -0.12 .90 ULCP 45 51.3 2.7 BCLP 9 48.3 2.8 3.1 1.0 3.05 .003 372-472 distance UCLA 151 52.1 3.1 BCLA 16 52.1 2.8 0 0.7 -0.02 .98 ULCP 55 53.3 2.9 BCLP 12 52.1 2.8 1.2 0.9 1.36 .17 371-471 distance UCLA 145 54.5 3.3 BCLA 16 54.6 2.9 -0.1 0.8 -0.08 .93 ULCP 51 56.5 3.0 BCLP 12 55.2 2.7 1.3 0.9 1.48 .13
LOWER ARCH RATIO
UCLA 144 55.1 5.2 BCLA 16 56.2 3.6 -1.1 1.0 -1.08 .28 ULCP 45 53.8 4.6 BCLP 9 56.8 5.8 -3.0 2.0 -1.47 .14
DIFF = difference in arch width between UCLA and BCLA, UCLP and BCLP S.E = standard error of difference
LOWER ARCH RATIO = 331-431 distance / 361-461 distance * 100 (%)
3.4 Discussion and conclusions
Chapter 3
All transversal dimensions of the mandible from canine to second molar were measured and the differences found (table 3.1, 3.2, 3.3) would not have been noticed if measurements of the mandibular arch had been limited to one or two width measurements only as in the study of Polaczek (1992).
In th resent study the mandibular transversal dimensions were found y normal in cleft types where the palate was not involved H , lete UCLP, where the palate was nvolved, the mandibular transversal dimensions were wider than in the This finding corresponds with the outcome of A-P
th a er
onial an in unoper ed UCLP patients (Da Silvo Filho et al, 1993; al, 1994; Han et al, 1995), which suggests a skeletal
o rge di la h dth
onfirmed in a study on mandibular morphology in UCLP patients using
(C ag nst d th he
id ibl co is y rger n t of the non-cleft 2002). In our study for BCLP individuals no differences in
h w o H
is ver io c o ol
d unoperated BCLP patients have a wider intergonial width
arg l lar
s ; M s t 9 . P
ur study was too small (n=13) in order to draw reliable
pe .
ith bl a e
ifficult. Reliable transversal measurements of the
a e ila
measurements of Heidbüchel and Kuijpers-Jagtman (1997) and Polaczek 1992) were performed in patients that had, in majority, already undergone
ore it is not eally possible to make any reliable comparison with our sample. Also the ample of Nystrom et al (1992) is not really comparable with our series. r isolated cleft palate only and the sample as studied till the age of 6.
e p to be essentiall
(UCLA and BCLA). owever in comp i
control group.
cephalometric studies at showed larger int condylar width and a larger
g gle at
Motohashi et
backgr und for the la r man bu r arc wi . Recently this finding was c
computed tomography T) im ing that demo rate that e volume of t cleft s e hemi-mand e was ns tentl la tha tha
side (Lo et al,
mandibular dental arc idth c uld be found. owever, A-P cephalometric analys on the trans se cran fa ial m rph ogy has consistently shown that operated an
which is related to a l er mandibu ar intermo width (Ishiguro et al, 1976; Athana iou et al, 1990 otoha hi e al, 1 94) ossibly the sample of BCLP individuals in o
conclusions for this ty of cleft
A comparison w availa e d ta from th literature at the level of the alveolar process is d
untreated mandibular rch ar not yet ava ble in the literature. The (
orthodontic treatment, which could have influenced the development of the mandible, especially at the level of the alveolar process. Theref
r s
Thei group consists of patients with w
dimensions are wider. For BCLP this was not found, probably due to the small sample size for this type of cleft. Whether this widening of the lower dental arch is related to a wider maxillary dental arch in complete unoperated clefts needs to be investigated further.
75. DA S
, HILL MJ, CALCOTE CE, KARESH SH, LIFSCHIZ 3.5 References
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BISHARA SE, ARRENDONDO RS, VALES HP, JACOBSEN JR. Dentofacial relationship in patients with unoperated cleft; comparison between three cleft types. Am J Orthod 1985;87:481-507.
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DA SILVA FILHO OG, NORMANDO AD, CAPELOZZA FILHO L. Mandibular morphology and spatial position in patients with cleft: Intrinsic or iatrogenic? Cleft Palate Craniofac J 1992a;29:369-3
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HEIDBÜCHEL KLWM, KUIJPERS-JAGTMAN AM. Maxillary and mandibular dental arch dimensions and occlusion in BCLP patients from 3 to 17 years of age. Cleft Palate Craniofac J 1997;34:21-26.
M, MAZAHERI M, HARDING RL. A longitudinal study of morphological craniofacial patterns via P-A X-ray headfilms in cleft patients
LO L in patients with
MOT
alate. Cleft Palate
NYST
with isolated cleft palate. Scand J Dent Res 1992;
POLA ete cleft lip and
ROB
ISHIGURO K, KROGMAN W
from birth to six years of age. Cleft Palate J 1976;13:104-126. J, WONG FH, CHEN YR, WONG HF. Mandibular dysmorphology
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OHASHI N, KURODA T, CAPELOZZA FILHO L, DE SOUZA FREITAS JA. P-A cephalometric analysis of non-operated adult cleft lip and p
Craniofac J 1994;31:193-200.
ROM M, RANTA R, KATAJA M. Sizes of dental arches and general body growth up to 6 years of age in children
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CZEK T. Late results of the surgical treatment in unilateral compl
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