The Cleft Palate–Craniofacial Journal 52(6) pp. e196–e200 November 2015 Ó Copyright 2015 American Cleft Palate–Craniofacial Association
ORIGINAL ARTICLE Association Between Dental Arch Widths and Interarch Relationships in Children With Operated Unilateral Complete Cleft Lip and Palate Patrı´cia Bittencourt Dutra dos Santos, D.D.S., M.Sc., Guilherme Janson, D.D.S., M.Sc., Ph.D., Vivian Helena Assis, Maira de Paula Leite Battisti, Daniela Gamba Garib, D.D.S., M.Sc., Ph.D. Objective: Palate and lip repair have great influence on the sagittal and transverse growth of the maxilla. The correlation between arch widths and sagittal interarch relationships in operated patients with complete unilateral cleft lip and palate (UCLP) in the mixed dentition is not clear. The aim of this study was to compare the maxillary arch widths of patients with UCLP and different interarch relationships (GOSLON Yardstick index). Methods: The study sample consisted of 144 pairs of dental casts of patients with complete UCLP from 8 to 10 years of age, from a single center. These dental casts were divided into three groups: group I (patients with GOSLON Yardstick 1 and 2 interarch relationships), group II (GOSLON Yardstick 3), and group III (GOSLON Yardstick 4 and 5). The control group consisted of 40 pairs of dental casts of noncleft Class I patients at the same age range. The maxillary and mandibular arch widths were measured at canine, deciduous molars, and permanent first molar regions. Intergroup comparisons were performed by analysis of variance followed by Tukey tests (P , .05). Results: Maxillary arch widths were significantly smaller in all three groups with repaired UCLP compared to the control group. Group III showed reduced intercanine and second deciduous molar widths compared to group I. No intergroup differences were observed for mandibular arch widths. Conclusions: Operated UCLP patients with more severe sagittal discrepancies tend to show more severe transverse maxillary arch deficiencies. KEY WORDS:
cleft lip, cleft palate, dental arch
Orofacial clefts are a frequent malformation in the population and require early surgery repair for esthetic and functional reasons. However, the primary plastic repair of complete cleft lip and palate affects facial growth and dental occlusion in the three planes of space in the long-term, and it is still not clear whether the amount of maxillary sagittal deficiency is directly related to the amount of transverse deficiency in repaired patients with unilateral cleft lip and palate (UCLP) (Semb, 1991a, 1991b; Normando et al., 1992; Liao and Lin, 2009; Bartzela et al., 2011; Chiu and Liao, 2012). Several methods of recording dental relationships have been reported. The GOSLON Yardstick (Mars et al., 1987)
is a rating system developed specifically for rating dental arch relationships in children with UCLP. This index mainly indicates the sagittal relationship of the maxilla. A number of studies have also investigated arch dimensions in patients with cleft lip and palate. Athanasiou et al. (1988) investigated dental arch dimensions in patients with UCLP and found that all maxillary interdental widths and lengths were significantly smaller than a control group without cleft. Blanco et al. (1989) longitudinally analyzed and compared the maxillary dental arch dimensions of a group of patients of both sexes with complete UCLP, after 12 years of age, with those of a control group of noncleft individuals. They concluded that the intercanine and intermolar widths of patients with UCLP were smaller than those of the control group. To our knowledge, only DiBiase et al. (2002) investigated the correlation of maxillary sagittal deficiency with transverse arch dimensions in individuals with cleft. They evaluated how the dimensions of the dental arches in children in the deciduous dentition with repaired UCLP related to the categories of an established index of treatment outcome. Arch dimensions of patients with clefts showed shorter and narrower maxillary arches in the poorer categories of the index.
Dr. Garib is Associate Professor, Department of Orthodontics, Hospital of Rehabilitation of Craniofacial Anomalies; Dr. dos Santos is orthodontic graduate student; Dr. Janson is Professor, Department of Orthodontics, Bauru Dental School, University of Sa˜o Paulo, Brazil; and Mss. Assis and Battisti are dentistry undergraduate students, Bauru Dental School, University of Sa˜o Paulo, Bauru, SP, Brazil. Submitted July 2012; Accepted March 2013. Address correspondence to: Dr. Daniela Gamba Garib, Department of Orthodontics, Bauru Dental School, University of Sa˜o Paulo, Alameda Octa´vio Pinheiro Brisolla 9–75, Bauru, SP 17012-901, Brazil. E-mail [email protected]. DOI: 10.1597/12-171 e196
Garib et al., ASSOCIATION BETWEEN DENTAL ARCH WIDTHS AND INTERARCH RELATIONSHIPS
FIGURE 1 arches.
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Distances of arch widths in the maxillary and mandibular
Therefore, the aim of this study was to compare the dental arch widths of patients with repaired UCLP and different anteroposterior interarch relationships (GOSLON Yardstick index) in the mixed dentition. The null hypothesis was that operated patients with UCLP with and without sagittal maxillary deficiency have similar maxillary and mandibular dental arch widths. MATERIALS
AND
METHODS
This project was approved by the Ethical Committee of the Hospital for Rehabilitation of Craniofacial Anomalies, University of Sa˜o Paulo (HRCA-USP), and informed consent was obtained for each patient. Two samples of dental casts were selected for this study: a study sample of 104 patients with complete UCLP from the records of the HRCA-USP and a control group consisting of 40 pairs of dental casts of noncleft Class I patients from the study growth center of the Bauru Dental School, University of Sa˜o Paulo, matched by age and sex with the study sample. The inclusion criteria of the study sample were patients with isolated unilateral cleft lip and palate, presence of an adequate pair of dental casts taken between 8 and 10 years of age, and history of lip and palate repair performed in the first year of life, and palate repair within the second year of life. The exclusion criterion was the presence of early loss of deciduous molars. The primary surgeries had been carried out by five different surgeons using the Millard technique for lip repair and the Van Langenbeck technique for palate repair. The study sample was divided into three groups according to the GOSLON Yardstick index by a single examiner:
Group I: 35 patients with GOSLON Yardstick index of 1 and 2; Group II: 32 patients with GOSLON Yardstick index of 3; and Group III: 37 patients with GOSLON Yardstick index of 4 and 5.
Measurements of arch widths were performed in the maxillary and mandibular arches (Fig. 1). The interdeciduous canine, interpermanent molar, and the distances between the first and second deciduous molars were
FIGURE 2 casts.
Measurements using a digital caliper directly on dental
measured using a digital caliper directly on dental casts by a single examiner (Fig. 2). Distance measurements were obtained between cusp tips of canines, cusp tips of first deciduous molars, mesiobuccal cusp tips of second deciduous molars, and mesiobuccal cusp tips of first permanent molars (Fig. 1). Estimated cusp tips were used in cases of wear facets. Error Study In order to assess the study error, measurements of 24 pairs of dental casts were repeated by the same operator 1 month after the first evaluation. Random and systematic errors were assessed using Dahlberg formula and dependent t tests, respectively. Statistical Analyses After confirmation of normal distribution of the data using the Kolmogorov-Smirnov test, intergroup comparisons for arch widths were performed using one-way analysis of variance (ANOVA) followed by Tukey tests.
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TABLE 1
Systematic and Casual Errors (Dependent t Tests and Dahlberg Formula) 18 Measurement (N ¼ 24)
28 Measurement (N ¼ 24)
Variables
Mean
SD
Mean
SD
P
Dahlberg
Maxillary Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
26.60 35.67 41.91 49.06
3.34 3.81 3.30 3.59
26.52 35.59 41.68 48.75
3.70 3.52 3.11 3.49
0.742 0.682 0.386 0.054
0.77 0.61 0.86 0.56
Mandibular Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
25.65 32.23 38.25 45.26
2.33 2.93 3.01 3.79
25.44 32.25 38.24 45.23
2.32 2.35 2.85 3.62
0.117 0.943 0.978 0.883
0.44 1.01 1.08 0.89
The significance level of 5% was considered. The statistical analyses were performed with SPSS 7.0 for Windows (SPSS Inc., Chicago, IL).
to be transverse constriction. This is more severe in the medial and anterior regions and can be attributed to medial displacement of the palatal segments, especially the minor segment (da Silva Filho et al., 1992; DiBiase et al., 2002). In the mixed dentition, the degree of constriction of the maxillary arch in patients with repaired UCLP is an important factor when considering the impact of primary surgeries on growth (Joos, 1995; Kramer et al., 1996; Adcock and Markus, 1997; Markus and Precious, 1997). In the present study, there were differences in the transverse dimensions of the maxillary arch between subjects with repaired clefts and those without clefts (Table 2). Narrower arches were observed in the repaired cleft groups. Constriction was slight in the molar region and more pronounced in the anterior regions. This means that the influence of cleft and primary surgeries is markedly greater in the anterior region of the dental arch (da Silva Filho et al., 1992). Similar reduction of maxillary arch dimensions in children with repaired UCLP in different ages has been found previously (Robertson and Fish, 1975; Wada et al., 1984; Athanasiou et al., 1988; Kramer et al., 1996; DiBiase et al., 2002). Presence of cleft and primary surgeries does not seem to have an influence on mandibular arch transverse dimensions. The lack of any significant difference in linear mandibular arch dimensions between UCLP and control subjects in the present study is consistent with findings of other studies (Derijcke et al., 1994; DiBiase et al., 2002) (Table 3). The GOSLON Yardstick has been shown to be a robust measurement tool with a high degree of reliability and
RESULTS The error study results are shown in Table 1. There were no statistically significant systematic errors, and the random errors were within acceptable range. The widths at the anterior and midsections of the maxillary arch were found to be significantly smaller in the cleft groups compared to the control group, with the exception of the second deciduous molar width of group I (Table 2). Group III (GOSLON 4 and 5) had significantly smaller intercanine and second deciduous molar widths than group I (GOSLON 1 and 2). The maxillary permanent first molar width was similar in patients with and without cleft. There was no significant difference for the mandibular arch dimensions among all groups (Table 3). DISCUSSION A consistent finding in patients with repaired UCLP is constriction of the maxillary arch, with shortened maxillary arch length and narrowing of intercanine and intermolar widths. How much of this is directly related to the nature of the primary surgery has been fiercely debated (Athanasiou et al., 1988; da Silva Filho et al., 1992; DiBiase et al., 2002). Although maxillary arch length in adults with UCLP with unoperated clefts approaches normality, there still appears TABLE 2
Intergroup Comparison of Maxillary Arch Widths (ANOVA Followed by Tukey Tests) Mean (SD)†
Maxillary Arch Widths (mm) Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
Group I (N ¼ 35) 28.53 36.54 43.46 49.77
B
(4.29) (4.01)A (3.41)BC (4.41)
* Statistically significant at P , .05. † A, B, C ¼ Different letters mean statistically significant difference.
Group II (N ¼ 32) 26.49 35.85 42.36 48.86
AB
(3.63) (4.06)A (3.72)AB (3.98)
Group III (N ¼ 37) 25.86 35.18 40.99 50.72
A
(3.08) (3.12)A (2.21)A (3.46)
Control Group (N ¼ 40) 34.11 39.74 43.13 49.59
C
(1.80) (2.14)B (3.42)C (3.64)
P .000* .000* .000* .073
Garib et al., ASSOCIATION BETWEEN DENTAL ARCH WIDTHS AND INTERARCH RELATIONSHIPS
TABLE 3
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Intergroup Comparison of Mandibular Arch Widths (ANOVA) Mean (SD)
Mandibular Arch Widths (mm) Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
Group I (N ¼ 35) 26.01 33.07 38.65 45.66
(3.00) (3.32) (3.56) (4.10)
Group II (N ¼ 32) 26.23 32.94 39.05 46.24
reproducibility and has proven useful for longitudinal assessment of dental arch relationship. Application of the Yardstick is simple and fast, requiring no specialized or expensive equipment. It does not involve application of precise and detailed criteria but relies on a simple method of judgment. The simplicity is its inherent strength, and its longitudinal robustness makes it a valuable tool. The Yardstick considers clinically important variables in all three planes of space and allows ranking of dental models in order of difficulty to achieve a favorable outcome (Chan et al., 2003; Mars et al., 2006). For this reason, GOSLON Yardstick was used in this study. The current study observed an association between anteroposterior interarch relationships and maxillary arch widths in children with operated complete UCLP in the mixed dentition. Patients with greater interarch anteroposterior discrepancies showed smaller transverse maxillary arch dimensions. Patients classified as GOSLON Yardstick 4 and 5 showed smaller intercanine and second deciduous molar widths compared to patients with interarch GOSLON Yardstick indexes 1 and 2 (Table 2). GOSLON Yardstick 3 patients showed similar maxillary arch widths compared to GOSLON Yardstick 1 and 2 patients. The explanations for the association between maxillary anteroposterior deficiency and anterior maxillary constriction may rely on the fact that lip repair could cause continuous pressure on the anterior portion of the maxillary dental arch, influencing both the maxillary sagittal growth and the transverse dimension in the anterior region of the maxillary arch (Normando et al., 1992). The greater the lip tension after primary surgeries, the greater the maxillary sagittal deficiency and the constriction in the anterior region. Similar findings have been reported for the deciduous dentition in studies using the 5-year-old index (DiBiase et al., 2002; Garrahy et al., 2005). These studies showed correlations between maxillary intercanine width and anteroposterior interarch relationships, with narrower intercanine widths in the more severe sagittal interarch discrepancies. Conversely, the widths in the posterior region of the maxillary arch (permanent intermolar widths) were not affected by the cleft, the surgical repair, and the anteroposterior interarch relationship, in accordance with DiBiase et al. (2002) (Table 2). Therefore, the anterior and midsection of the maxillary arch are more constricted in patients with operated UCLP. Additionally, the greater the maxillary sagittal deficiency, the smaller is the transverse
(2.50) (2.38) (2.76) (2.94)
Group III (N ¼ 37) 25.94 32.88 38.69 46.06
(2.48) (2.88) (2.39) (2.64)
Control Group (N ¼ 40) 27.24 33.50 38.78 45.20
(1.69) (1.90) (2.00) (2.08)
P .088 .074 .937 .450
dimension of these arch sections. These findings are important for orthodontic treatment planning. The majority of patients with repaired UCLP will demand more expansion in the anterior region of the palate. The amount of expansion required for patients with GOSLON Yardstick indexes 4 and 5 will probably be greater compared to patients with GOSLON Yardstick indexes 1, 2, and 3. The association between arch widths and sagittal interarch relationship can be an indicator in the primary dentition to quantify the outcome of the primary treatment. It will clearly identify development of the maxillary arch of patients and whether correction of the resulting malocclusion can be accomplished with orthodontics or surgical intervention (DiBiase et al., 2002). CONCLUSIONS The null hypothesis was rejected because patients with greater maxillary anteroposterior deficiencies present smaller transverse dimensions of the maxillary arch. However, mandibular arch width is not affected by the sagittal interarch relationships. REFERENCES Adcock S, Markus AF. Mid-facial growth following functional cleft surgery. Br J Oral Maxillofac Surg. 1997;35:1–5. Athanasiou AE, Mazaheri M, Zarrinnia K. Dental arch dimensions in patients with unilateral cleft lip and palate. Cleft Palate J. 1988;25:139–145. Bartzela T, Katsaros C, Ronning E, Rizell S, Semb G, Bronkhorst E, Halazonetis D, Kuijpers-Jagtman AM. A longitudinal three-center study of craniofacial morphology at 6 and 12 years of age in patients with complete bilateral cleft lip and palate. Clin Oral Investig. 2011;16:1313–1324. Blanco R, Fuchslocher G, Bruce L. Variations in arch and tooth size in the upper jaw of cleft palate patients [in Spanish]. Odontol Chil. 1989;37:221–229. Chan KT, Hayes C, Shusterman S, Mulliken JB, Will LA. The effects of active infant orthopedics on occlusal relationships in unilateral complete cleft lip and palate. Cleft Palate Craniofac J. 2003;40:511– 517. Chiu YT, Liao YF. Is cleft severity related to maxillary growth in patients with unilateral cleft lip and palate? Cleft Palate Craniofac J. 2012;49:535–540. da Silva Filho OG, Ramos AL, Abdo RC. The influence of unilateral cleft lip and palate on maxillary dental arch morphology. Angle Orthod. 1992;62:283–290.
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Derijcke A, Kuijpers-Jagtman AM, Lekkas C, Hardjowasito W, Latief B. Dental arch dimensions in unoperated adult cleft-palate patients: an analysis of 37 cases. J Craniofac Genet Dev Biol. 1994;14:69–74. DiBiase AT, DiBiase DD, Hay NJ, Sommerlad BC. The relationship between arch dimensions and the 5-year index in the primary dentition of patients with complete UCLP. Cleft Palate Craniofac J. 2002;39:635–640. Garrahy A, Millett DT, Ayoub AF. Early assessment of dental arch development in repaired unilateral cleft lip and unilateral cleft lip and palate versus controls. Cleft Palate Craniofac J. 2005;42:385– 391. Joos U. Skeletal growth after muscular reconstruction for cleft lip, alveolus and palate. Br J Oral Maxillofac Surg. 1995;33:139–144. Kramer GJ, Hoeksma JB, Prahl-Andersen B. Early palatal changes after initial palatal surgery in children with cleft lip and palate. Cleft Palate Craniofac J. 1996;33:104–111. Liao YF, Lin IF. Dental arch relationships after two-flap palatoplasty in Taiwanese patients with unilateral cleft lip and palate. Int J Oral Maxillofac Surg. 2009;38:1133–1136. Markus AF, Precious DS. Effect of primary surgery for cleft lip and palate on mid-facial growth. Br J Oral Maxillofac Surg. 1997;35:6– 10.
Mars M, Batra P, Worrell E. Complete unilateral cleft lip and palate: validity of the five-year index and the Goslon yardstick in predicting long-term dental arch relationships. Cleft Palate Craniofac J. 2006;43:557–562. Mars M, Plint DA, Houston WJ, Bergland O, Semb G. The Goslon Yardstick: a new system of assessing dental arch relationships in children with unilateral clefts of the lip and palate. Cleft Palate J. 1987;24:314–322. Normando AD, da Silva Filho OG, Capelozza Filho L. Influence of surgery on maxillary growth in cleft lip and/or palate patients. J Craniomaxillofac Surg. 1992;20:111–118. Robertson NR, Fish J. Early dimensional changes in the arches of cleft palate children. Am J Orthod. 1975;67:290–303. Semb G. A study of facial growth in patients with unilateral cleft lip and palate treated by the Oslo CLP Team. Cleft Palate Craniofac J. 1991a;28:1–21. Semb G. A study of facial growth in patients with bilateral cleft lip and palate treated by the Oslo CLP Team. Cleft Palate Craniofac J. 1991b;28:22–39. Wada T, Mizokawa N, Miyazaki T, Ergen G. Maxillary dental arch growth in different types of cleft. Cleft Palate J. 1984;21:180–192.
ORIGINAL ARTICLE Association Between Dental Arch Widths and Interarch Relationships in Children With Operated Unilateral Complete Cleft Lip and Palate Patrı´cia Bittencourt Dutra dos Santos, D.D.S., M.Sc., Guilherme Janson, D.D.S., M.Sc., Ph.D., Vivian Helena Assis, Maira de Paula Leite Battisti, Daniela Gamba Garib, D.D.S., M.Sc., Ph.D. Objective: Palate and lip repair have great influence on the sagittal and transverse growth of the maxilla. The correlation between arch widths and sagittal interarch relationships in operated patients with complete unilateral cleft lip and palate (UCLP) in the mixed dentition is not clear. The aim of this study was to compare the maxillary arch widths of patients with UCLP and different interarch relationships (GOSLON Yardstick index). Methods: The study sample consisted of 144 pairs of dental casts of patients with complete UCLP from 8 to 10 years of age, from a single center. These dental casts were divided into three groups: group I (patients with GOSLON Yardstick 1 and 2 interarch relationships), group II (GOSLON Yardstick 3), and group III (GOSLON Yardstick 4 and 5). The control group consisted of 40 pairs of dental casts of noncleft Class I patients at the same age range. The maxillary and mandibular arch widths were measured at canine, deciduous molars, and permanent first molar regions. Intergroup comparisons were performed by analysis of variance followed by Tukey tests (P , .05). Results: Maxillary arch widths were significantly smaller in all three groups with repaired UCLP compared to the control group. Group III showed reduced intercanine and second deciduous molar widths compared to group I. No intergroup differences were observed for mandibular arch widths. Conclusions: Operated UCLP patients with more severe sagittal discrepancies tend to show more severe transverse maxillary arch deficiencies. KEY WORDS:
cleft lip, cleft palate, dental arch
Orofacial clefts are a frequent malformation in the population and require early surgery repair for esthetic and functional reasons. However, the primary plastic repair of complete cleft lip and palate affects facial growth and dental occlusion in the three planes of space in the long-term, and it is still not clear whether the amount of maxillary sagittal deficiency is directly related to the amount of transverse deficiency in repaired patients with unilateral cleft lip and palate (UCLP) (Semb, 1991a, 1991b; Normando et al., 1992; Liao and Lin, 2009; Bartzela et al., 2011; Chiu and Liao, 2012). Several methods of recording dental relationships have been reported. The GOSLON Yardstick (Mars et al., 1987)
is a rating system developed specifically for rating dental arch relationships in children with UCLP. This index mainly indicates the sagittal relationship of the maxilla. A number of studies have also investigated arch dimensions in patients with cleft lip and palate. Athanasiou et al. (1988) investigated dental arch dimensions in patients with UCLP and found that all maxillary interdental widths and lengths were significantly smaller than a control group without cleft. Blanco et al. (1989) longitudinally analyzed and compared the maxillary dental arch dimensions of a group of patients of both sexes with complete UCLP, after 12 years of age, with those of a control group of noncleft individuals. They concluded that the intercanine and intermolar widths of patients with UCLP were smaller than those of the control group. To our knowledge, only DiBiase et al. (2002) investigated the correlation of maxillary sagittal deficiency with transverse arch dimensions in individuals with cleft. They evaluated how the dimensions of the dental arches in children in the deciduous dentition with repaired UCLP related to the categories of an established index of treatment outcome. Arch dimensions of patients with clefts showed shorter and narrower maxillary arches in the poorer categories of the index.
Dr. Garib is Associate Professor, Department of Orthodontics, Hospital of Rehabilitation of Craniofacial Anomalies; Dr. dos Santos is orthodontic graduate student; Dr. Janson is Professor, Department of Orthodontics, Bauru Dental School, University of Sa˜o Paulo, Brazil; and Mss. Assis and Battisti are dentistry undergraduate students, Bauru Dental School, University of Sa˜o Paulo, Bauru, SP, Brazil. Submitted July 2012; Accepted March 2013. Address correspondence to: Dr. Daniela Gamba Garib, Department of Orthodontics, Bauru Dental School, University of Sa˜o Paulo, Alameda Octa´vio Pinheiro Brisolla 9–75, Bauru, SP 17012-901, Brazil. E-mail [email protected]. DOI: 10.1597/12-171 e196
Garib et al., ASSOCIATION BETWEEN DENTAL ARCH WIDTHS AND INTERARCH RELATIONSHIPS
FIGURE 1 arches.
e197
Distances of arch widths in the maxillary and mandibular
Therefore, the aim of this study was to compare the dental arch widths of patients with repaired UCLP and different anteroposterior interarch relationships (GOSLON Yardstick index) in the mixed dentition. The null hypothesis was that operated patients with UCLP with and without sagittal maxillary deficiency have similar maxillary and mandibular dental arch widths. MATERIALS
AND
METHODS
This project was approved by the Ethical Committee of the Hospital for Rehabilitation of Craniofacial Anomalies, University of Sa˜o Paulo (HRCA-USP), and informed consent was obtained for each patient. Two samples of dental casts were selected for this study: a study sample of 104 patients with complete UCLP from the records of the HRCA-USP and a control group consisting of 40 pairs of dental casts of noncleft Class I patients from the study growth center of the Bauru Dental School, University of Sa˜o Paulo, matched by age and sex with the study sample. The inclusion criteria of the study sample were patients with isolated unilateral cleft lip and palate, presence of an adequate pair of dental casts taken between 8 and 10 years of age, and history of lip and palate repair performed in the first year of life, and palate repair within the second year of life. The exclusion criterion was the presence of early loss of deciduous molars. The primary surgeries had been carried out by five different surgeons using the Millard technique for lip repair and the Van Langenbeck technique for palate repair. The study sample was divided into three groups according to the GOSLON Yardstick index by a single examiner:
Group I: 35 patients with GOSLON Yardstick index of 1 and 2; Group II: 32 patients with GOSLON Yardstick index of 3; and Group III: 37 patients with GOSLON Yardstick index of 4 and 5.
Measurements of arch widths were performed in the maxillary and mandibular arches (Fig. 1). The interdeciduous canine, interpermanent molar, and the distances between the first and second deciduous molars were
FIGURE 2 casts.
Measurements using a digital caliper directly on dental
measured using a digital caliper directly on dental casts by a single examiner (Fig. 2). Distance measurements were obtained between cusp tips of canines, cusp tips of first deciduous molars, mesiobuccal cusp tips of second deciduous molars, and mesiobuccal cusp tips of first permanent molars (Fig. 1). Estimated cusp tips were used in cases of wear facets. Error Study In order to assess the study error, measurements of 24 pairs of dental casts were repeated by the same operator 1 month after the first evaluation. Random and systematic errors were assessed using Dahlberg formula and dependent t tests, respectively. Statistical Analyses After confirmation of normal distribution of the data using the Kolmogorov-Smirnov test, intergroup comparisons for arch widths were performed using one-way analysis of variance (ANOVA) followed by Tukey tests.
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TABLE 1
Systematic and Casual Errors (Dependent t Tests and Dahlberg Formula) 18 Measurement (N ¼ 24)
28 Measurement (N ¼ 24)
Variables
Mean
SD
Mean
SD
P
Dahlberg
Maxillary Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
26.60 35.67 41.91 49.06
3.34 3.81 3.30 3.59
26.52 35.59 41.68 48.75
3.70 3.52 3.11 3.49
0.742 0.682 0.386 0.054
0.77 0.61 0.86 0.56
Mandibular Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
25.65 32.23 38.25 45.26
2.33 2.93 3.01 3.79
25.44 32.25 38.24 45.23
2.32 2.35 2.85 3.62
0.117 0.943 0.978 0.883
0.44 1.01 1.08 0.89
The significance level of 5% was considered. The statistical analyses were performed with SPSS 7.0 for Windows (SPSS Inc., Chicago, IL).
to be transverse constriction. This is more severe in the medial and anterior regions and can be attributed to medial displacement of the palatal segments, especially the minor segment (da Silva Filho et al., 1992; DiBiase et al., 2002). In the mixed dentition, the degree of constriction of the maxillary arch in patients with repaired UCLP is an important factor when considering the impact of primary surgeries on growth (Joos, 1995; Kramer et al., 1996; Adcock and Markus, 1997; Markus and Precious, 1997). In the present study, there were differences in the transverse dimensions of the maxillary arch between subjects with repaired clefts and those without clefts (Table 2). Narrower arches were observed in the repaired cleft groups. Constriction was slight in the molar region and more pronounced in the anterior regions. This means that the influence of cleft and primary surgeries is markedly greater in the anterior region of the dental arch (da Silva Filho et al., 1992). Similar reduction of maxillary arch dimensions in children with repaired UCLP in different ages has been found previously (Robertson and Fish, 1975; Wada et al., 1984; Athanasiou et al., 1988; Kramer et al., 1996; DiBiase et al., 2002). Presence of cleft and primary surgeries does not seem to have an influence on mandibular arch transverse dimensions. The lack of any significant difference in linear mandibular arch dimensions between UCLP and control subjects in the present study is consistent with findings of other studies (Derijcke et al., 1994; DiBiase et al., 2002) (Table 3). The GOSLON Yardstick has been shown to be a robust measurement tool with a high degree of reliability and
RESULTS The error study results are shown in Table 1. There were no statistically significant systematic errors, and the random errors were within acceptable range. The widths at the anterior and midsections of the maxillary arch were found to be significantly smaller in the cleft groups compared to the control group, with the exception of the second deciduous molar width of group I (Table 2). Group III (GOSLON 4 and 5) had significantly smaller intercanine and second deciduous molar widths than group I (GOSLON 1 and 2). The maxillary permanent first molar width was similar in patients with and without cleft. There was no significant difference for the mandibular arch dimensions among all groups (Table 3). DISCUSSION A consistent finding in patients with repaired UCLP is constriction of the maxillary arch, with shortened maxillary arch length and narrowing of intercanine and intermolar widths. How much of this is directly related to the nature of the primary surgery has been fiercely debated (Athanasiou et al., 1988; da Silva Filho et al., 1992; DiBiase et al., 2002). Although maxillary arch length in adults with UCLP with unoperated clefts approaches normality, there still appears TABLE 2
Intergroup Comparison of Maxillary Arch Widths (ANOVA Followed by Tukey Tests) Mean (SD)†
Maxillary Arch Widths (mm) Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
Group I (N ¼ 35) 28.53 36.54 43.46 49.77
B
(4.29) (4.01)A (3.41)BC (4.41)
* Statistically significant at P , .05. † A, B, C ¼ Different letters mean statistically significant difference.
Group II (N ¼ 32) 26.49 35.85 42.36 48.86
AB
(3.63) (4.06)A (3.72)AB (3.98)
Group III (N ¼ 37) 25.86 35.18 40.99 50.72
A
(3.08) (3.12)A (2.21)A (3.46)
Control Group (N ¼ 40) 34.11 39.74 43.13 49.59
C
(1.80) (2.14)B (3.42)C (3.64)
P .000* .000* .000* .073
Garib et al., ASSOCIATION BETWEEN DENTAL ARCH WIDTHS AND INTERARCH RELATIONSHIPS
TABLE 3
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Intergroup Comparison of Mandibular Arch Widths (ANOVA) Mean (SD)
Mandibular Arch Widths (mm) Intercanine width First deciduous molar width Second deciduous molar width Permanent first molar width
Group I (N ¼ 35) 26.01 33.07 38.65 45.66
(3.00) (3.32) (3.56) (4.10)
Group II (N ¼ 32) 26.23 32.94 39.05 46.24
reproducibility and has proven useful for longitudinal assessment of dental arch relationship. Application of the Yardstick is simple and fast, requiring no specialized or expensive equipment. It does not involve application of precise and detailed criteria but relies on a simple method of judgment. The simplicity is its inherent strength, and its longitudinal robustness makes it a valuable tool. The Yardstick considers clinically important variables in all three planes of space and allows ranking of dental models in order of difficulty to achieve a favorable outcome (Chan et al., 2003; Mars et al., 2006). For this reason, GOSLON Yardstick was used in this study. The current study observed an association between anteroposterior interarch relationships and maxillary arch widths in children with operated complete UCLP in the mixed dentition. Patients with greater interarch anteroposterior discrepancies showed smaller transverse maxillary arch dimensions. Patients classified as GOSLON Yardstick 4 and 5 showed smaller intercanine and second deciduous molar widths compared to patients with interarch GOSLON Yardstick indexes 1 and 2 (Table 2). GOSLON Yardstick 3 patients showed similar maxillary arch widths compared to GOSLON Yardstick 1 and 2 patients. The explanations for the association between maxillary anteroposterior deficiency and anterior maxillary constriction may rely on the fact that lip repair could cause continuous pressure on the anterior portion of the maxillary dental arch, influencing both the maxillary sagittal growth and the transverse dimension in the anterior region of the maxillary arch (Normando et al., 1992). The greater the lip tension after primary surgeries, the greater the maxillary sagittal deficiency and the constriction in the anterior region. Similar findings have been reported for the deciduous dentition in studies using the 5-year-old index (DiBiase et al., 2002; Garrahy et al., 2005). These studies showed correlations between maxillary intercanine width and anteroposterior interarch relationships, with narrower intercanine widths in the more severe sagittal interarch discrepancies. Conversely, the widths in the posterior region of the maxillary arch (permanent intermolar widths) were not affected by the cleft, the surgical repair, and the anteroposterior interarch relationship, in accordance with DiBiase et al. (2002) (Table 2). Therefore, the anterior and midsection of the maxillary arch are more constricted in patients with operated UCLP. Additionally, the greater the maxillary sagittal deficiency, the smaller is the transverse
(2.50) (2.38) (2.76) (2.94)
Group III (N ¼ 37) 25.94 32.88 38.69 46.06
(2.48) (2.88) (2.39) (2.64)
Control Group (N ¼ 40) 27.24 33.50 38.78 45.20
(1.69) (1.90) (2.00) (2.08)
P .088 .074 .937 .450
dimension of these arch sections. These findings are important for orthodontic treatment planning. The majority of patients with repaired UCLP will demand more expansion in the anterior region of the palate. The amount of expansion required for patients with GOSLON Yardstick indexes 4 and 5 will probably be greater compared to patients with GOSLON Yardstick indexes 1, 2, and 3. The association between arch widths and sagittal interarch relationship can be an indicator in the primary dentition to quantify the outcome of the primary treatment. It will clearly identify development of the maxillary arch of patients and whether correction of the resulting malocclusion can be accomplished with orthodontics or surgical intervention (DiBiase et al., 2002). CONCLUSIONS The null hypothesis was rejected because patients with greater maxillary anteroposterior deficiencies present smaller transverse dimensions of the maxillary arch. However, mandibular arch width is not affected by the sagittal interarch relationships. REFERENCES Adcock S, Markus AF. Mid-facial growth following functional cleft surgery. Br J Oral Maxillofac Surg. 1997;35:1–5. Athanasiou AE, Mazaheri M, Zarrinnia K. Dental arch dimensions in patients with unilateral cleft lip and palate. Cleft Palate J. 1988;25:139–145. Bartzela T, Katsaros C, Ronning E, Rizell S, Semb G, Bronkhorst E, Halazonetis D, Kuijpers-Jagtman AM. A longitudinal three-center study of craniofacial morphology at 6 and 12 years of age in patients with complete bilateral cleft lip and palate. Clin Oral Investig. 2011;16:1313–1324. Blanco R, Fuchslocher G, Bruce L. Variations in arch and tooth size in the upper jaw of cleft palate patients [in Spanish]. Odontol Chil. 1989;37:221–229. Chan KT, Hayes C, Shusterman S, Mulliken JB, Will LA. The effects of active infant orthopedics on occlusal relationships in unilateral complete cleft lip and palate. Cleft Palate Craniofac J. 2003;40:511– 517. Chiu YT, Liao YF. Is cleft severity related to maxillary growth in patients with unilateral cleft lip and palate? Cleft Palate Craniofac J. 2012;49:535–540. da Silva Filho OG, Ramos AL, Abdo RC. The influence of unilateral cleft lip and palate on maxillary dental arch morphology. Angle Orthod. 1992;62:283–290.
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