Dental Arch Width in Unoperated Cleft Patients Latief, Benny S.

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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

Version: Corrected Publisher’s Version

License: Licence agreement concerning inclusion of doctoral thesis in the_{Institutional Repository of the University of Leiden} Downloaded from: https://hdl.handle.net/1887/649

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Chapter 6

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Summary

This chapter deals with the question whether the width of the palatal cleft is determined by real shortage of tissue in the palatal area or whether the width of the cleft is related to malposition of the palatal shelves or a combination of both factors. Therefore the purpose of this study has been to investigate the width and elevation of the palatal shelves in unoperated adult UCLP and BCLP in comparison with a non-cleft control group. The width and elevation of the palatal shelves were measured on dental casts of 81 fully unoperated patients from Indonesia of whom 68 had a complete UCLP and 13 a complete BCLP and compared to a control non-cleft sample (n=24) of the same population.

In unoperated UCLP patients the width of the palatal shelves at the cleft side was significantly smaller in comparison with the control group. The same holds good for the non-cleft side, except in the canine / first premolar region. The unoperated BCLP subjects showed the same pattern although the difference with the controls was not significant for every dimension. In comparison with the control group the angle of the palatal shelves in the UCLP subjects was larger which means that the palatal shelves are rotated cranially and are more vertically positioned. Also in BCLP the angle of the palatal shelves was almost 10 degrees more in comparison with the control group. The palatal shelf elevation was not significantly different between the two cleft groups.

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Chapter 6

6.1 Introduction

One of the major problems in the treatment of cleft lip and palate is disturbance of maxillary growth. Whether the cause of the abnormal maxillary growth is related to an intrinsic primary defect or should be considered as a secondary defect caused by iatrogenic factors such as surgical repair in early childhood or orthodontic treatment, or both, is not yet fully understood. Dahl (1970) and Bishara (1973) suggested that there are significant differences in dentofacial relationships between patients with untreated unilateral complete cleft lip, alveolus, and palate (UCLP) and non-cleft subjects. The effect of the lip and/or palate surgery is therefore assumed to be superimposed on intrinsic deficiencies of the dentofacial structures.

In general, studies on facial growth in cleft lip and palate patients are mainly carried out on patients who have already undergone operations for repair of the cleft in early childhood (Mazaheri et al, 1967). In an attempt to estimate the effect of surgery on subsequent facial growth, several research groups started to study dental and facial development in unoperated adult cleft patients whose dentofacial growth is assumed to be undisturbed (Innis, 1962; Bishara et al, 1985; Hardjowasito and Latief, 1988; Hardjowasito, 1989; Capelozza et al, 1996). The study of adult unoperated cleft patients is also useful for a better understanding of the differences among various types of clefts while eliminating the superimposing effects of surgical or orthodontic treatment (Bishara et al, 1976, 1985, 1986). Previous studies on maxillofacial growth in untreated patients with clefts have led to the conclusion that surgery must be considered to be a major factor in maxillary retrusion. (Ortiz-Monasterio et al, 1959; Mestre et al, 1960; Ortiz-Monasterio et al, 1966; Schweckendiek, 1978).

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deviations in individuals with clefts are not intrinsic to the cleft itself, but are a secondary effect that is specific for a certain type of cleft. In the second group it is assumed that there is a real shortage of tissue in cleft palate patients. Lo et al (2003) studied the surface area of the palate in four different unoperated groups of cleft patients at 3 months of age, using three-dimensional computed tomography images of dental casts. The findings suggest that compared with cleft lip or cleft palate only patients, there is an intrinsic tissue deficiency in the palate/maxilla of BCLP and UCLP patients.

This chapter deals with the question whether the width of the palatal cleft is determined by real shortage of tissue in the palatal area or whether it is related to malposition of the palatal shelves, or a combination of both factors. Therefore the purpose of this study was to investigate the width and elevation of the palatal shelves in different types of unoperated adult cleft patients.

6.2 Material and methods

The measurements were performed on dental casts of patients with unoperated UCLP (n=68) and BCLP (n=13). 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).

Figure 6.1 Palatal shelf width and elevation measurements.

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Chapter 6

The dental casts were digitized according to the protocol as described in chapter 2. The points related to teeth are described with the number of the proper teeth, followed by a number indicating the position of the point on the tooth. In the present chapter for each maxillary first molar two points were used: the tip of the distobuccal cusp and the point at the gingiva, where the fissure is located between the mesial and distal palatal cusp (point 3, see figure 6.1). The points, numbered 4, are located at the cleft margins on an imaginary line connecting the points 3 at left and right side of the maxilla for each tooth (in UCLP and BCLP only). In the control group the points 4 of the left and right side coincide in the midline of the palate. In the case of abrasion of a cusp, the centre of the abraded cusp was used as the reference point. The following distances (in mms) and angles (in degrees) were calculated:

173 - 174 palatal shelf width right side at the level of the second molar 273 - 274 palatal shelf width left side at the level of the second molar 163 - 164 palatal shelf width right side at the level of the first molar 263 - 264 palatal shelf width left side at the level of the first molar

153 - 154 palatal shelf width right side at the level of the second premolar 253 - 254 palatal shelf width left side at the level of the second premolar 143 - 144 palatal shelf width right side at the level of the first premolar 243 - 244 palatal shelf width left side at the level of the first premolar 133 - 134 palatal shelf width right side at the level of the canine 233 - 234 palatal shelf width left side at the level of the canine

163 - 164 / 161 - 261: palatal shelf elevation at the right side, defined as the angle between the line 161 – 261 and the line 163 - 164, representing the palatal shelf at the right side (see above).

263 - 264 / 161 - 261: palatal shelf elevation at the left side, defined as the angle between the line 161 – 261 and the line 263 - 264, representing the palatal shelf at the left side (see above).

Means and standard deviations were calculated for all variables. Occasionally reference points were missing or teeth had been extracted. Therefore the numbers differ per variable.

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statistically significant difference between the two, the mean of both shelves was taken to compare with the cleft and non-cleft side in UCLP. The level of significance was set at p<0.05. No alpha correction was made for multiple comparisons. The calculations were performed with SPSS version 11.0.

6.3 Results

Means and sd (in mm) for the width of the palatal shelves at the cleft side at the level of the canine, first premolar, second premolar, first molar, and second molar in unoperated UCLP as compared to BCLP and the control group are summarized in table 6.1. Box-whisker plots for the width of the palatal shelves (in mm) for the cleft and non-cleft subjects are shown in figure 6.2. 23 24 23 23 24 13 13 13 12 11 66 66 68 62 69 62 66 65 59 63 N = element type M2 M1 P2 P1 C palatinal shelf (mm) 40 30 20 10 0 GROUP UCLP-Cleft UCLP-nonC BCLP Control

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Chapter 6

Table 6.1 Width of the palatal shelves (in mm) at the cleft and non-cleft side in unoperated UCLP subjects compared to BCLP and controls.

UCLP-C = UCLP cleft side UCLP-N = UCLP non-cleft side

GROUP N MEAN SD GROUP N MEAN SD DIFF S.E t-VALUE p-VALUE

PALATAL SHELF CANINE REGION

UCLP-C 63 9.1 2.8 Control 24 13.9 1.1 -4.9 0.6 -8.48 .00005 UCLP-N 68 15.5 2.8 Control 24 13.9 1.1 1.4 0.6 2.56 .02 BCLP 11 12.2 5.0 Control 24 13.9 1.1 -1.7 1.5 -1.18 .27 UCLP-C 63 9.1 2.8 BCLP 11 12.2 5.0 -3.1 1.0 -3.04 .07 UCLP-N 68 15.5 2.8 BCLP 11 12.2 5.0 3.2 1.0 3.10 .0002

PALATAL SHELF FIRST PREMOLAR REGION

UCLP-C 62 14.2 2.7 Control 22 16.9 0.9 -2.7 0.4 -4.83 .00005 UCLP-N 66 16.8 2.2 Control 23 16.9 0.9 -0.1 0.4 -0.33 .86 BCLP 13 15.6 3.3 Control 23 16.9 0.9 -1.3 1.0 -1.39 .19 UCLP-C 62 14.2 2.7 BCLP 13 15.6 3.3 -1.4 0.9 -1.67 .10 UCLP-N 66 16.8 2.2 BCLP 13 15.6 3.3 1.2 0.7 1.68 .10

PALATAL SHELF SECOND PREMOLAR REGION

PALATAL SHELF FIRST MOLAR REGION

PALATAL SHELF SECOND MOLAR REGION

UCLP-C 59 19.7 3.0 Control 23 24.9 1.7 -5.2 0.7 -7.87 .00005 UCLP-N 62 21.0 3.3 Control 23 24.9 1.7 -3.9 0.7 -5.39 .00005 BCLP 12 19.0 2.8 Control 23 24.9 1.7 -5.9 0.8 -7.53 .00005 UCLP-C 59 19.7 3.0 BCLP 12 19.0 2.8 0.7 0.9 0.69 .49 UCLP-N 62 21.0 3.3 BCLP 12 19.0 2.8 2.0 1.0 2.10 .05

DIFF = difference in width of the palatal shelves between two groups. The width of the palatal shelf in BCLP is defined as the mean of the width of the palatal shelves of left and right side

S.E = standard error

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In UCLP the width of the palatal shelves at the cleft side was significantly smaller in comparison with the control group. The same holds true for the non-cleft side except in the canine/first premolar region. The BCLP subjects showed the same pattern. Furthermore the width of the palatal shelf at the cleft side UCLP (UCLP-C) did not differ significantly from the shelf width in BCLP.

Means and sd (in degrees) for the elevation of the palatal shelves at the level of the first molar are given in table 6.2. Box-whisker plots of the palatal shelf elevation at the level of the first molar are shown in figure 6.3. In comparison with the control group the angle of the palatal shelves in the UCLP subjects at the cleft and non-cleft side was larger which means that the palatal shelves are rotated cranially and are more vertically positioned. Also in BCLP the angle of the palatal shelves was almost 10 degrees more than in comparison with the control group. The palatal shelf elevation was not significantly different between the two cleft groups.

24 12 68 65 N = GROUP Control BCLP UCLP-nonC UCLP-Cleft

shelf angle (deg)

70 60 50 40 30 20

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Chapter 6

Table 6.2 Palatal shelf elevation (in degrees) at the cleft and non-cleft side in unoperated UCLP subjects compared to BCLP and controls.

UCLP-C = UCLP cleft side UCLP-N = UCLP non-cleft side

GROUP N MEAN SD GROUP N MEAN SD DIFF S.E t-VALUE p-VALUE UCLP-C 65 47.3 7.0 Control 24 39.0 4.2 8.4 1.5 5.5 .000 UCLP-N 68 49.3 6.3 Control 24 39.0 4.2 10.3 1.4 7.5 .000 BCLP 12 48.7 6.3 Control 24 39.0 4.2 9.8 1.8 5.6 .000 UCLP-C 65 47.3 7.0 BCLP 12 48.7 6.3 -1.4 2.2 -0.6 .520 UCLP-N 68 49.3 6.3 BCLP 12 48.7 6.3 0.5 2.0 0.3 .794

DIFF = difference in palatal shelves elevation between two groups. The elevation of the palatal shelf in BCLP is defined as the mean of the elevation of the palatal shelves of left and right side

S.E = standard error

6.4 Discussion and conclusions

The total sample size in this study and the number of patients in each investigated group are sufficient to allow some preliminary conclusions on the investigated variables. In UCLP and BCLP patients the palatal shelf width was clearly smaller than in the non-cleft control group. This finding suggests a deficiency in the amount of available tissue, not only at the cleft side but also at the supposedly normally developed non-cleft side.

This is in agreement with Lo et al (2003) who performed a three-dimensional surface analysis of the palatal shelves on dental casts of 3-months-old babies before any operation. The BCLP and UCLP groups had a significantly smaller palatal surface area than the unilateral cleft lip without cleft palate (UCL) and isolated cleft palate (CP) groups. There were no significant differences between the BCLP and UCLP groups. Their findings also suggest that, compared with UCL and CP patients, there is an intrinsic tissue deficiency in the palate/maxilla of BCLP and UCLP patients.

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incomplete and complete UCLP at birth, that the palate in complete UCLP, compared with incomplete UCLP, showed more curvature. Interposition of the tongue between the palatal shelves, which are not connected to each other, might be responsible for this upward rotation of the shelves.

The clinical implications of these findings are obvious. The smaller palatal shelf width and the larger elevation of the shelves result in a wider cleft. The surgeon trying to bridge the gap, especially when using the Langenbeck technique, creates a great empty space between the elevated palatal mucosa and the denudated bone of the palatal shelves. The scar tissue developing between these two structures contracts with a possibly final result of transversal compression of the maxilla and malpositioning of the teeth, as frequently seen in the early operated cleft lip, alveolus and palate patients. Therefore there is an urgent need to design surgical techniques that take into account the intrinsic deviations, which might result in better long-term dentomaxillary development.

6.5 References

BISHARA SE. Cephalometric evaluation of facial growth in operated and non-operated individuals with isolated clefts of the palate. Cleft Palate J 1973;3:239-246.

BISHARA SE, KRAUSE CJ, OLIN WH, WESTON D, NESS JV, FELLING C. Facial and dental relationship of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J 1976;13:238-252.

BISHARA SE, SOSA-MARTINEZ R, PATRON-VALES HP, JAKOBSEN JR. Dentofacial relationship in persons with unoperated clefts: comparisons between three cleft types. Am J Orthod 1985;87:481-506.

BISHARA SE, JAKOBSEN JR, KRAUSE JC, SOSA-MARTINEZ R. Cephalometric comparisons of individuals from India and Mexico with unoperated cleft lip and palate. Cleft Palate J 1986;23:116-125.

CAPELOZZA FILHO L, NORMANDO AD, DA SILVA FILHO OG. Isolated influences of lip and palate surgery on facial growth: Comparison of operated and unoperated male adults with UCLP. Cleft Palate Craniofac J 1996;33:51-56.

DAHL E. Craniofacial morphology in congenital clefts of the lip and palate. An X-ray cephalometric study of young adult males. Acta Odont Scand 1970;28:1-167.

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Chapter 6

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HARDJOWASITO W. Studi sumbing bibir dan langit2 unilateral pada penderita-penderita akil baliq dan dewasa yang belum dioperasi. Disertasi Universitas Airlangga. Surabaya (Indonesia); 1989.

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ORTIZ-MONASTERIO F, REBEIL AS, VALDERAMO M, CRUZ R. Cephalometric measurement on adult patients with nonoperated cleft palates. Plast Reconstr Surg 1959;24:54-61.

ORTIZ-MONASTERIO F, SERRANO A, BARRERA G, RODRIGUEZ-HOFFMAN H, VINAGERAS E. A study of untreated adult cleft palate patients. Plast Reconstr Surg 1966;38:36-41.

SCHWECKENDIEK W. Primary veloplasty: long-term results without maxillary deformity. A twenty five year report. Cleft Palate J 1978;15:268-273.

VAN LIMBORG J. Some aspects of the development of the cleft affected face. In: Early Treatment of Cleft Lip and Palate. R Hotz (Ed). Berne-Stuttgart: Hans Huber; 1964. pp 25-29.