ORIGINAL PAPERs Dent. Med. Probl. 2014, 51, 2, 193–196 ISSN 1644-387X
© Copyright by Wroclaw Medical University and Polish Dental Society
Anna Maria Paradowska-Stolarz
Dental Arch Symmetry in Patients with Total Clefts Symetria łuków zębowych u pacjentów z rozszczepem całkowitym Department of Dentofacial Anomalies, Department of Orthodontics and Dentofacial Orthopedics, Wroclaw Medical University, Wrocław, Poland
Abstract Background. Among the many characteristics of clefts, there is asymmetry. It applies to both the patient’s facial and intraoral conditions. The asymmetry includes the bones and soft tissues of the patient with cleft and points to the greatest extent around the nose, subnasal region and upper lip on the clefted side. Objectives. The aim of the study was to determine the prevalence of symmetry and asymmetry of the dental arches of patients with cleft lip integers, alveolar process and palate. Material and Methods. Measurements of dental arches symmetry were made on plaster casts. Measurements of 154 patients with clefts (36 patients with bilateral cleft, 87 – with left and 31 – the right) and 151 patients without congenital deformities were taken into account. Results. The symmetry of the upper dental arch in patients with unilateral cleft is practically not observed. Among patients with bilateral cleft, maxillary symmetry is at a similar level as in healthy patients (it concerns 100% of men and only 25% of women with bilateral cleft). Mandibular arch is symmetrical relatively frequently in all groups, and this observation applies to approximately 60–70% of patients. Conclusions. Lack of symmetry of the dental arch of the maxilla in patients with unilateral clefts was observed. In patients with bilateral clefts, upper dental arch symmetry is at the same level as in the case of healthy subjects. The symmetry of the lower dental arch is observed at comparable levels in patients with clefts and patients without this malformation (Dent. Med. Probl. 2014, 51, 2, 193–196). Key words: total cleft, cleft lip and palate, dental arch symmetry.
Streszczenie Wprowadzenie. Jedną z wielu cech charakteryzujących rozszczepy jest asymetria. Dotyczy zarówno rysów twarzy pacjenta, jak i warunków wewnątrzustnych. Asymetria obejmuje kości oraz tkanki miękkie pacjenta z rozszczepem i zaznacza się w największym stopniu w okolicy nosowej, podnosowej i górnej wargi po stronie objętej wadą rozwojową. Cel pracy. Określenie częstości występowania symetrii i asymetrii łuków zębowych u pacjentów z rozszczepami całkowitymi wargi, wyrostka zębodołowego i podniebienia. Materiał i metody. Pomiary symetrii łuków zębowych wykonano na modelach gipsowych. Pomiarom poddano 154 modele łuków zębowych pacjentów z rozszczepami (36 pacjentów z rozszczepem obustronnym, 87 z lewostronnym i 31 z prawostronnym) oraz 151 modeli łuków zębowych pacjentów bez współistniejących wad rozwojowych. Wyniki. Symetria górnego łuku zębowego u pacjentów z rozszczepem jednostronnym nie jest praktycznie obserwowana. Wśród pacjentów z rozszczepem obustronnym symetria szczęki jest na podobnym poziomie, jak u pacjentów zdrowych (dotyczy zatem 100% mężczyzn i jedynie 25% kobiet). Łuk zębowy w żuchwie jest symetryczny porównywalnie często we wszystkich badanych grupach, a obserwacja ta dotyczy około 60–70% badanych. Wnioski. Zaobserwowano brak symetrii łuku zębowego szczęki u pacjentów z rozszczepem jednostronnym. W przypadku pacjentów z rozszczepem obustronnym symetria górnego łuku zębowego jest podobna do tej u pacjentów zdrowych. Symetria dolnego łuku zębowego jest obserwowana na porównywalnym poziomie w grupach pacjentów z rozszczepami i pacjentów bez wady rozwojowej (Dent. Med. Probl. 2014, 51, 2, 193–196). Słowa kluczowe: symetria łuku zębowego, rozszczep wargi i podniebienia, rozszczep całkowity.
194 Cleft lip and palate is the most common orofacial deformity that is observed in 1:700–1:2500 live births and it depends on the gender and race. The inheritance pattern is multifactorial. The genes responsible for clefts are “triggered” by environmental causes (such as avitaminosis, teratogenes, ethanol, metabolic disorders etc.). Clefts of the lip are caused by a disturbance in the junction within the philtrum – the nasal processes of the left and right side which fail to join in 5th–6th week of pregnancy; this is followed by a failure in junction of the maxillary processes. Clefts of the palate occur due to the disturbances in the elevation of palatal shelves between the days 43 and 60 in utero (22–46 mm CRL) [1, 2]. Patients with cleft deformities develop threedimensional underdevelopment of maxilla that leads to a narrowing and flattening of the maxilla observed intraorally as a crossbite [3]. Hong Kong researchers [4] proved that most of the patients (92.3% of men and 71.4% of women) represent severe malocclusions that include mainly crossbites, class III malocclusions and midline shifts. The asymmetry in dentoalveolar bone is mostly accentuated at the canine, as the arch is flattened on this side most severely [5]. Surgical procedures to restore the maxillary bone and receive continuity within the alveolar bone, including bone grafting are required [1]. According to Swanson et al. [5], class III malocclusions are observed unilaterally at 1/3 cases of clefts as a result of maxillary underdevelopment. The asymmetry is caused by rotation of the underbalanced part of the maxilla. The deviation of this part may cause measuring errors in cephalometric analysis, as this may cause the apparent elongation of the maxilla. Computed tomography shows that the dentoalveolar region on the cleft side is significantly retruded, while the other midfacial regions show no significant differences when the symmetry is deliberated. The asymmetry within the arch is observed when one of the lateral incisors is missing, which is observed in ca. 50% of the cases [3, 5–8]. The asymmetry is also observed in the mandible. This is accented by a deviation of chin to the cleft side [9]. Turkish researchers [10] reported that the head posture is elongated due to the disturbed relation between the skull and spine, but the vertical dimension of the head remains comparable to healthy individuals. Natural head posture, achieved when seated or standing patient feels comfortable, might also be disturbed due to the asymmetry of the body posture [10, 11]. Facial asymmetry in cleft individuals is observed in patients with unilateral clefts three times more frequently than in bilateral cleft individuals and six times more often than in healthy pa-
A.M. Paradowska-Stolarz
tients [6]. The asymmetry does not refer only to the bone, but is also observed in the soft tissues of nasolabial and dentoalveolar regions. The observations show that the soft tissues are thicker and positioned more anteriorly on the cleft side [7]. The asymmetry is mostly pronounced in the nasolabial region. A characteristic flattening and widening of the nostril on the affected side is caused by the presence of the scar after reconstructive procedures. Asymmetry is also observed in the upper labial region [6, 7]. The performed surgical procedures probably lead to the shortening of nasal length, which does not change much at the puberty [12]. The asymmetry is also observed when the patient is smiling. The outer features, including the smile are perceived by the society as less attractive [6, 7, 13].
Material and Methods Dental casts of 154 patients with total clefts of the lip, alveolar bone and palate were compared to 151 casts of healthy individuals with orthodontic treatment needs. The inclusion criteria included lack of plaster cast breakage, full permanent dentition eruption (at least to the first permanent molar) that was confirmed by panoramic X-ray. Among the patients with clefts, bilateral cleft (BCLP) was observed in 36 cases (17 women, 19 men), left-sided cleft (CLP-L) – in 87 cases (36 women, 51 men), right-sided cleft (CLP-R) – in 31 cases (8 women, 23 men). The control group composed of 96 women and 55 men. All of the patients were not previously treated with fixed appliances, though they were under the orthodontic care. The mean age of the examined group was 13.18 years (patients aged from 7.1 to 20 years) and the mean age of the control group was similar (13.44 years). The age was estimated basing on the time of dental casts preparation. The arch symmetry was established in maxilla due to the palatal midline. In the mandible the symmetry was established according to the line between genial spike (or, in case that it is not visualized on the cast, tondue frenulum) and the point that was stated on the projected distal point of the palatal line to the mandible when casts were lodged. The symmetry was established with the use of a symetroscope with a millimeter scale. The measurement points were first permanent molars, first premolars, canines and central incisors. If any of the points on the left and right side deviated from the symmetry, the arch was established as asymmetrical. When the observed deviation was 1 mm or less, the arch was treated as symmetrical. To show the difference between the control and examined groups, frequency tables were used.
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Dental Arch Symmetry in Patients with Total Clefts Table 1. Dental arch symmetry in the maxilla Tabela 1. Symetria łuku zębowego w szczęce CLP-R
CLP-L
BCLP
Control
Men
1 (4.35%)
2 (3.92%)
19 (100%)
36 (65.45%)
Women
0 (0%)
0 (0%)
4 (23.53%)
50 (52.08%)
Table 2. Dental arch symmetry in the mandible Tabela 2. Symetria łuku zębowego w żuchwie CLP-R
CLP-L
BCLP
Control
Men
13 (56.52%)
36 (70.59%)
17 (87.80%)
41 (74.55%)
Women
5 (62.50%)
26 (72.22%)
12 (70.59%)
57 (59.38%)
Results As presented in Table 1, the asymmetry in maxilla is observed in almost 100% of the patients with unilateral clefts. In patients with bilateral clefts, a symmetrical arch is observed in almost half of the cases, which is comparable to healthy individuals. What is interesting, the maxilla is symmetric in all male patients with BCLP, while as it is observed only in 25% girls with this type of deformity. Table 2 presents the measurements of symmetry concerning the mandibular arch. The symmetry of the lower arch reaches 60–70% in all the examined groups and does not differ much between the examined and control groups. The highest percentage of mandibular symmetry is observed in patients with bilateral clefts.
Discussion The facial asymmetry in patients with clefts is widely discussed in the literature. It refers to both hard and soft tissues [3, 5–8]. In the presented study, researchers proved that in cleft patients the asymmetry is observed also intraorally and refers to the upper dental arch mainly. This observation might be a result of three-dimensional underdevelopment of the maxilla that leads to the flattening of the affected side and the formation of the crossbite, most severely observed in the canine region [3, 5]. The results of computed tomography investigations also show asymmetry within the
upper dental arch of the cleft individuals [7]. In the present study, the symmetry within the upper arch was barely observed in unilateral cleft individuals, while the symmetry of the maxilla was observed with the same frequency in patients with bilateral clefts when compared to the healthy individuals. The observations of asymmetry in the present study are much higher than those performed by Swanson et al. [5] that observed asymmetry in ca. one third of the cleft individuals. Observations that facial asymmetry is more frequent in unilateral cleft patients were presented by Bugaighis et al. [6]. In the English population asymmetry of the face is observed three times more frequently compared to patients with unilateral and bilateral cleft deformity and six times more frequently when compared to healthy individuals. The English study also does not fully match the study presented in this paper. The common feature is an observation of the greater turnout of asymmetry in unilateral cleft lip and palate patients. The difference refers to patients with bilateral clefts. In the present study, the symmetry in the upper dental arch in those patients is observed equally often when compared to the healthy individuals, while in the study presented by Bugaighis et al. the symmetry is observed twice less often [6]. The symmetry of the mandibular dental arch is comparable in patients with various types of total clefts and healthy individuals. The maxillary arch shows high asymmetry in patients with unilateral clefts. The upper arch in bilateral cleft individuals is rather symmetric, as in the healthy individuals.
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[3] Sikora T., Strzałkowska A.: Orthodontic treatment of an adult patient with left-sided cleft lip and palate and a congenitally missing lateral incisor. Dent. Med. Probl. 2013, 50, 96–105. [4] Tang E.L.K., Lisa L.Y.: Prevalence and severity of malocclusion in children with cleft lip and/or palate in Hong Kong. Cleft Palate Craniofac. J. 1992, 29, 287–291. [5] Swanson L.T., MacCollum D.W., Richardson S.O.: Evaluation of the dental problems in the cleft patients. Am. J. Orthod. 1956, 42, 449–465. [6] Bugaighis I., O’Higgins P., Tiddeman B., Mattick C., Ben Ali O., Hobson R.: Three-dimensional geometric morphometrics applied to the study of children with cleft lip and/or palate from the North East of England. Eur. J. Orthod. 2010, 32, 514–521. [7] Choi Y.K., Park S.B., Kim Y.I., Son W.S.: Three-simensional evaluation of the midfacial asymmetry in the patients with nonsyndromic unilateral cleft lip and palate by cone-beam computed tomography. Kor. J. Orthod. 2013, 43, 113–119. [8] Tortora C., Meazzini M.C., Garrattini G., Brusati R.: Prevalence of abnormalities In dental structure, position and eruption pat tern in a population of unilateral and bilateral cleft lip and palate patients. Cleft Palate Craniofac. J. 2008, 45, 154–162. [9] Kim K.S., Son Wo.S., Park S.B., Kim S.S., Kim Y.I.: Relationship between chin deviation and the position and morphology of the mandible in individuals with a unilateral cleft lip and palate. Kor. J. Orthod. 2013, 43, 168–177. [10] Yücel-Eroğlu E., Gulsen A., Uner O.: Head posture in cleft lip and palate patients with oronasal fistula and its relationship with craniofacial morphology. Cleft Palate Craniofac. J. 2007, 44, 402–411. [11] Woźniak K., Piątkowska D., Lipski M.: The influence of natural head position on the assessment of facial morphology. Adv. Clin. Exp. Med. 2012, 21, 743–749. [12] Antoszewski B., Kruk-Jeromin J., Malinowski A.: The developmental difference in children with bilateral cleft lip, alveolus and palate. Czas. Stomatol. 1995, 48, 597–600 [in Polish]. [13] Kryściak R., Kozłowski Z., Czernik M.R.: Gingival smile as a complex problem of aesthetic dentistry. Dent. Med. Probl. 2013, 50, 362–368.
Address for correspondence: Anna Maria Paradowska-Stolarz Department of Dentofacial Anomalies Wroclaw Medical University Krakowska 26 50-425 Wrocław Poland E-mail:
[email protected] Conflict of interest: None declared Received: 23.03.2014 Revised: 3.04.2014 Accepted: 29.04.2014 Praca wpłynęła do Redakcji: 23.03.2014 r. Po recenzji: 3.04.2014 r. Zaakceptowano do druku: 29.04.2014 r.
