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Evaluation of dehiscence and fenestration in adolescents affected by bilateral cleft lip and palate using cone-beam computed tomography
ORIGINAL ARTICLE
Evaluation of dehiscence and fenestration in adolescents affected by bilateral cleft lip and palate using cone-beam computed tomography Mevlut Celikoglu,a Suleyman Kutalmis Buyuk,b Mukerrem Hatipoglu,c Ahmet Ercan Sekerci,d and Mehmet Ertugrul Ciftcie Antalya, Ordu, and Kayseri, Turkey
Introduction: We evaluated the dehiscence and fenestration presence in maxillary and mandibular anterior teeth of patients affected by bilateral cleft lip and palate (BCLP) and compared the findings with a well-matched control group of noncleft patients using cone-beam computed tomography. Methods: Conebeam computed tomography images of 51 patients were divided into 2 groups (group 1, 21 patients affected by BCLP; mean age; 14.62 6 2.89 years; and group 2, 30 patients as the noncleft control group; mean age, 14.22 6 1.05 years) and assessed them for dehiscence and fenestration in the anterior maxillary and mandibular teeth. Data were analyzed with the Student t test, Pearson chi-square test, and Fischer exact test. Results: The prevalences of dehiscence in patients affected by BCLP were 61.11% in the maxillary and 48.41% in the mandibular anterior teeth, whereas the rates in the noncleft group were 7.78% and 16.67%, respectively (P \ 0.001). The presence of fenestration was found to be statistically significantly higher in the maxillary central incisors of the BCLP group compared with the noncleft controls (P\0.05), and almost similar rates were noted for the other teeth, with no statistically significant differences (P . 0.05). Conclusions: Our data suggest that patients affected by BCLP may have higher prevalences of dehiscence in the maxillary and mandibular anterior teeth and of fenestration in the maxillary central incisors. (Am J Orthod Dentofacial Orthop 2017;152:458-64)
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left lip and palate (CLP) is a common craniofacial birth defect; several reasons, including genetic and environmental factors, may be responsible for the etiology and pathogenesis of this congenital malformation.1-3 Patients affected by CLP have complaints of mouth breathing, snoring, and hypopnea during sleep, and also have feeding, speaking, hearing, and esthetic
a Department of Orthodontics, Faculty of Dentistry, Akdeniz University, Antalya, Turkey. b Department of Orthodontics, Faculty of Dentistry, Ordu University, Ordu, Turkey. c Department of Periodontology, Faculty of Dentistry, Akdeniz University, Antalya, Turkey. d Private practice, Kayseri, Turkey. e Private practice, Antalya, Turkey. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Mevlut Celikoglu, Department of Orthodontics, Faculty of Dentistry, Akdeniz University, Dumlupianar Bulvari, Antalya, Turkey 07058; e-mail, [email protected]. Submitted, June 2016; revised and accepted, January 2017. 0889-5406/$36.00 Ó 2017 by the American Association of Orthodontists. All rights reserved. http://dx.doi.org/10.1016/j.ajodo.2017.01.024
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problems.4-6 Previous studies investigating the craniofacial development of these patients reported that anterior and posterior crossbite, midface deficiency with a tendency toward a Class III malocclusion, increased vertical dimensions, and decreased pharyngeal airway volume were commonly seen with this deformity.5-9 In addition, these patients were reported to be at risk for the development of periodontitis and mucogingival problems.10 Salvi et al11 reported a high incidence of plaque and bleeding on probing and a high level of periodontal attachment loss in these patients. Ercan et al12 reported reduced bone support that may cause some problems during orthodontic treatment at teeth near the cleft region compared with the noncleft region. Reduced alveolar support of the teeth might be a complicating factor during orthodontic treatment, and there is an increased risk of exacerbating or creating alveolar defects including dehiscence and fenestration.13 Although some studies investigated dehiscence and fenestration in patients with different sagittal and vertical malocclusions, it was almost neglected for the
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Table I. Criteria for sample selection Inclusion criteria BCLP Complete BCLP group Surgical closure of the lip and palate before the age of 3 years Good quality images Control Normal healthy group subjects Good quality images
Exclusion criteria Previous orthodontic (fixed or removable appliances) and prosthodontic treatment History of trauma Previous orthognathic surgery Cleft presence Syndrome presence Previous orthodontic and prosthodontic treatment History of trauma Previous orthognathic surgery
patients affected by CLP.14-16 Buyuk et al17 evaluated dehiscence and fenestration in the maxillary anterior teeth of patients affected by unilateral CLP (UCLP) using cone-beam computed tomography (CBCT) and reported that those patients had statistically significantly higher prevalences of dehiscences on the maxillary central and lateral incisors and canines, and a higher prevalence of fenestrations on the maxillary central incisors compared with noncleft patients. No previous study has evaluated the alveolar defects of dehiscence and fenestration in adolescent patients affected by bilateral CLP (BCLP). Thus, the aim of this study was to evaluate the dehiscences and fenestrations in maxillary and mandibular anterior teeth of patients affected by BCLP using CBCT. MATERIAL AND METHODS
We used the CBCT images that were part of the diagnostic records collected for dental and orthodontic treatment needs (presence of CLP, localization of impacted third molar before surgical extraction, pharyngeal airway assessment, and temporomandibular disorders) at Erciyes University in Kayseri, Turkey; no CBCTs were taken for the purpose of this study. The study was approved by the ethical committee of the same university. A power analysis was performed as described by Pandis and Machin,18 based on a significance level of 0.05 and a power of 80% to detect a clinically meaningful difference of 30% for the presence of dehiscence in maxillary central incisors between the groups using the findings of Buyuk et al,17 who reported statistically significant differences for patients affected by UCLP compared with noncleft controls (43% and 13%, respectively). Power analysis showed that 49 patients were needed for the study. According to the inclusion and exclusion criteria (Table I), the CBCT images of 51 patients were divided into 2 groups: group 1 consisted of 21 patients (3 girls,
18 boys; mean age, 14.62 6 2.89 years) affected by BCLP and group 2 consisted of 30 patients (8 girls, 22 boys; mean age, 14.22 6 1.05 years) as the control group without clefts. The patients affected by BCLP had no previous orthodontic treatment (fixed or removable appliances), and their CLP were surgically operated before the age of 3 years (Table I). All images had been obtained in standard operating conditions (CBCT scanning time, 18 seconds; collimation height, 13 cm; exposure time, 3.6 seconds; slice thickness, 0.25 mm; voxel size, 0.15 mm; and supine position) using the same machine (5G, QR; NewTom, Verona, Italy). Each 3-dimensional (3D) rendered image was reoriented using the Frankfort horizontal plane as the horizontal reference plane, constructed from the right and left porions, which are located in the most laterosuperior point of the external auditory meatus and the right and left orbitale, the most inferior point of the lower margin of the bony orbit. The sagittal reference plane was constructed from nasion and the midorbital point, perpendicular to the horizontal reference plane. The axial plane was constructed from nasion, perpendicular to the horizontal and sagittal planes. The images were transformed to DICOM format, and Simplant Pro software (version 16.0; Materialise, Leuven, Belgium) was used to evaluate the presence of dehiscences and fenestrations in the roots of maxillary and mandibular anterior teeth using the sagittal and axial slices at the buccal and lingual surfaces. Buccal and lingual surfaces of all maxillary and mandibular anterior teeth in the study (21 patients, 216 teeth) and control (30 patients, 360 teeth) were evaluated. It was classified as dehiscence when the alveolar bone height was more than 2 mm from the cementoenamel junction (Fig 1). When the defect did not involve the alveolar crest, it was classified as fenestration (Fig 2).19 All evaluations for dehiscence and fenestration were done by an experienced orthodontist (S.K.B.), who was previously trained for the study in random order without knowing the patients' groups. In addition, the same orthodontist assessed the sagittal and vertical growth patterns of the patients using ANB (1 \Class I \ 5 ; Class II . 5 ; Class III \1 )20 and SN-MP (high-angle group, .38 ; low-angle group, \26 ; normal-angle group, 26 –38 )21,22 parameters in both study and control groups with 3D cephalometry. Statistical analysis
To determine the random error, 20 CBCT images were randomly selected. All evaluations were blindly done 4 weeks after the first examination by the same orthodontist (S.K.B.). No difference was found for the presence of dehiscence and fenestration in the randomly
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Fig 1. Sagittal cross-sectional views of dehiscence (arrows) in the maxilla.
Fig 2. Sagittal cross-sectional views of fenestration (arrows) in the maxilla.
selected images, showing 100% agreement between the 2 readings. In addition, an experienced radiologist (A.E.S.) confirmed the agreement of the alveolar defect presence (100% agreement). The same author (S.K.B.) measured the ANB and SN-MP parameters, and the reliability of those measurements was tested with the Houston test.23 Statistical comparisons of alveolar defect prevalence and chronologic age distribution were done using the Pearson chi-square and Student t tests, respectively. Comparison of sex distributions between the groups was done using the Fisher exact test. All statistical analyses were performed using the SPSS software package for Windows (version 15.0; SPSS, Chicago, Ill), and P \ 0.05 was considered statistically significant. RESULTS
Intraexaminer and interexaminer reliability scores were 100% for the assessment of both dehiscence and fenestration. The Houston test23 confirmed the reliability of those measurements showing the growth patterns of the patients (r . 0.952). The comparisons of the chronologic ages (14.62 6 2.89 and 14.22 6 1.05 years, respectively) and sex distribution (female/male, 3/18 and 8/22, respectively) between the cleft and control groups showed that the groups were well matched according to the Student t and Pearson chi-square tests
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(P . 0.05). Most patients in the BCLP group had skeletal Class III malocclusions (10 patients) and low-angle growth patterns (9 patients), whereas the patients in the control group commonly had Class I malocclusions (26 patients) and normal-angle (27 patients) growth patterns (Table II). Statistical comparisons showed significant differences for both maxillary and mandibular anterior teeth between the BCLP and the control groups (P \ 0.001). Dehiscences were observed in 76.19% (32 of 42 teeth), 50.0% (3 of 6 teeth), and 47.62% (20 of 42 teeth) of the maxillary central incisors, lateral incisors, and canines, respectively. Those rates were statistically significantly higher compared with those of the noncleft controls (13.33%, 6.67%, and 3.34%, respectively) (P \ 0.001) (Table III). The BCLP group had statistically significantly high values for the mandibular central incisors (28 of 42 teeth; 66.67%), lateral incisors (18 of 42 teeth; 42.86%), and canines (15 of 42 teeth; 35.71%) compared with those of the noncleft controls (38.33%, 10.0%, and 1.67%, respectively). Dehiscence was commonly observed in both surfaces (28/55; 50.9%) of the maxillary anterior teeth, whereas it was more predominant in the buccal surface (35/61; 57.4%) of the mandibular anterior teeth in the BCLP group. On the other hand, it was more predominant in the lingual surfaces of the maxillary (13/14; 92.9%) and mandibular (25/30; 83.3%) anterior teeth in the control group.
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Table II. Distribution of chronologic ages, sexes, and growth patterns of the groups
BCLP group (n 5 21) Control group (n 5 30) P
Mean age (y) 14.62 6 2.89 14.22 6 1.05 0.555*
Female/Male 3/18 8/22 0.318y
Sagittal growth pattern
Vertical growth pattern
Class I/Class II/Class III 2/9/10 26/4/0
H-A/L-A/N-A 5/9/7 1/2/27
H-A, High angle; L-A, low angle; N-A, normal angle. *Results of Student t test; yresults of Fisher exact test.
Table III. Comparison of the dehiscence prevalence between the BCLP and control groups
Tooth type Maxillary central incisor Maxillary lateral incisor Maxillary canine Total Mandibular central incisor Mandibular lateral incisor Mandibular canine Total
BCLP group
Control group
Dehiscence presence
Dehiscence presence
Yes (%) 32/42 (76.19) 3/6 (50.0) 20/42 (47.62) 55/90 (61.11) 28/42 (66.67) 18/42 (42.86) 15/42 (35.71) 61/126 (48.41)
No (%) 10/42 (23.81) 3/6 (50.0) 22/42 (52.18) 35/90 (38.89) 14/42 (33.33) 24/42 (57.14) 27/42 (64.29) 65/126 (51.59)
Yes (%) 8/60 (13.33) 4/60 (6.67) 2/60 (3.34) 14/180 (7.78) 23/60 (38.33) 6/60 (10.0) 1/60 (1.67) 30/180 (16.67)
No (%) 52/60 (66.67) 56/60 (93.33) 58/60 (66.66) 166/180 (92.22) 37/60 (51.67) 54/60 (90.0) 59/60 (100.0) 150/180 (83.33)
P* 0.000 0.000 0.000 0.000 0.004 0.000 0.000 0.000
*Results of Pearson chi-square test.
Comparison of the fenestration prevalence between the BCLP and control groups showed that the BCLP group had statistically significantly higher values at the maxillary central incisors (5/42; 11.9%) compared with the noncleft control group (1/60; 1.67%) (P \ 0.05). Similar values were found for the other teeth in both groups with no statistically significant differences (P . 0.05) (Table IV). Fenestration was more predominant on the buccal surface of the maxillary anterior teeth (4/7; 57.14%) and was observed on the buccal surface of all mandibular anterior teeth in the BCLP group (4/4; 100%), and on all maxillary (6/6; 100%) and mandibular (6/6; 100%) anterior teeth in the control group. DISCUSSION
Previous studies have shown that alveolar dehiscence and fenestration are common in different types of malocclusions.14-16,24-26 The presence of those alveolar defects might cause gingival recession and additional bone loss during orthodontic treatment and thus greater potential for treatment relapse26,27 or unesthetic orthodontic treatment finishing.28,29 Since cleft patients have been reported to have several dental and skeletal malocclusions, it is important to detect their alveolar defects to perform a well-planned and organized orthodontic therapy.5,6,30,31 However, the
investigations of alveolar dehiscence and fenestration in patients affected by BCLP have been almost neglected in the literature; thus, this retrospective study was performed to present important findings about alveolar defects in BCLP patients. CBCT images were used to assess alveolar dehiscence and fenestration, since this technology has the potential to identify those defects without the disadvantages that are common in conventional radiographs.32-34 This technology is reported to be an important option for many clinical dental situations because of better image resolution, lower dose of radiation, and lower costs compared with multislice computed tomography.33,35 Therefore, the CBCT images obtained from the archive were used for this study. Intraexaminer and interexaminer reliability scores confirmed the excellent reproducibility and reliability of the CBCT images for assessment of the measurements performed in our study, as reported in previous studies.12,17,36 Buyuk et al17 reported 100% agreement of the CBCT images when used for the assessment of alveolar defects. Previous studies reported different values for dehiscence and fenestration in the teeth of various ethnic groups, ranging from 0.99% to 13.4% and from 0.23% to 16.9%, respectively.37-40 Increased prevalences of dehiscence and fenestration was
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Table IV. Comparison of fenestration prevalence between the BCLP and control groups
Tooth type Maxillary central incisor Maxillary lateral incisor Maxillary canine Total Mandibular central incisor Mandibular lateral incisor Mandibular canine Total
BCLP group
Control group
Fenestration presence
Fenestration presence
Yes (%) 5/42 (11.9) 1/6 (16.67) 1/42 (2.38) 7/90 (7.78) 3/42 (7.14) 1/42 (2.38) 0/42 (0.0) 4/126 (3.17)
No (%) 37/42 (97.62) 5/6 (83.33) 41/42 (97.62) 83/90 (92.22) 39/42 (92.86) 41/42 (97.62) 42/42 (100.0) 122/126 (96.83)
Yes (%) 1/60 (1.67) 3/60 (5.0) 2/60 (3.33) 6/180 (3.33) 3/60 (5.0) 2/60 (3.33) 1/60 (1.67) 6/180 (3.33)
No (%) 59/60 (98.33) 57/60 (95.0) 58/60 (3.33) 174/180 (96.67) 57/60 (95.0) 58/60 (96.67) 59/60 (98.33) 174/180 (96.67)
P* 0.031 0.253 0.779 0.108 0.651 0.779 0.401 0.939
*Results of Pearson chi-square test.
reported in different sagittal and vertical malocclusions using CBCT.14-16,25 Sun et al25 reported that the prevalence of dehiscence was 61.57% in teeth, and the rate was 31.93% for fenestration in patients with skeletal Class III malocclusions. Increased rates of alveolar defects were also reported for the bimaxillary protrusion malocclusion.41 In the study of Evangelista et al,14 the prevalence of dehiscence (51.09%) was higher than that of fenestration (36.51%), and more frequent in Class I malocclusions compared with Class II Division 1 malocclusions. Several factors may have effects on these different rates of alveolar defects including ethnic differences, dental and skeletal malocclusions, increased or decreased inclination of the teeth, crowding, decreased buccal or lingual cortical bone thickness, and visualization of the periodontal ligament.14,37 In this study, the prevalence of dehiscence in patients affected by BCLP was 61.11% in the maxillary and 48.41% in the mandibular anterior teeth, whereas the rates in the noncleft group were 7.78% and 16.67%, respectively. Previous studies reported that patients affected by BCLP had retruded maxillae and mandibles, decreased maxillary and mandibular lengths, increased vertical growth patterns, and decreased maxillary and mandibular incisors compared with the noncleft controls.6,8 Increased rates of both dehiscence and fenestration in BCLP patients might be associated with their skeletal and dental characteristics. It might occur because of decreased cortical bone thickness of the maxillary anterior teeth near the cleft area as stated by Ercan et al.12 Garip et al42 reported that the teeth adjacent to an alveolar cleft are covered by a thin alveolar bone plate and a slight increase in the distance between the alveolar bone crest and the cementoenamel junction in the mesial and lingual aspects of canines adjacent to the cleft. The decreased bony support of those teeth might play a role for the alveolar defects. Another cause
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for increased defects might be the potential differences in socioeconomic status of the groups that could not be assessed in this study because of its retrospective design. A unique study assessed dehiscences and fenestrations in UCLP patients using CBCT but did not assess the mandibular teeth; the authors reported that maxillary anterior teeth in both cleft and noncleft sides had significantly higher rates of dehiscence compared with the noncleft group.17 Our findings for maxillary anterior teeth agreed with those of Buyuk et al.17 In addition to that finding, we found significantly higher dehiscence prevalence in the mandibular anterior teeth (central incisors, 66.67%; lateral incisors, 42.86%; and canines, 35.71%) compared with the noncleft group (central incisors, 38.33%; lateral incisors, 10.0%; and canines, 1.67%) (P \ 0.01). In contrast to the literature14-16,38 showing that fenestration was more common in the maxillary teeth, our study showed that it was similar in both arches of the noncleft group. The presence of fenestration was statistically significantly higher in the maxillary central incisors of the BCLP group (P \ 0.05), whereas almost similar rates were noted for the other teeth, with no statistically significant differences. This finding agrees with that of Buyuk et al17 reported for UCLP patients. The findings of patients affected by BCLP with a higher prevalence of alveolar defects in the maxillary and mandibular anterior teeth motivate us to caution clinicians to treat patients affected by CLP carefully during their orthodontic treatment. Clinicians who treat those patients should get a CBCT image before their orthodontic treatment, assess the teeth for dehiscence and fenestration, and plan the tooth movement in teeth with alveolar defects. On the other hand, our retrospective study had limitations because of its design. One limitation of the study
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was that the periodontal health of the patients in both groups could not be assessed clinically. The differences in periodontal health between the groups might have affected our findings. Further clinical studies are needed to evaluate the relationship of alveolar bone defects and periodontal problems. Another limitation was that the CBCT images used in this study were taken with 0.25mm slices that might be questionable to detect thin bone layers that are normally present in the anterior dental region.43 Future studies using less than 0.20 mm might be welcome to discuss and compare our findings. A limited number of study samples for the BCLP group is another concern. CONCLUSIONS
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12.
Within the limitations of this retrospective study, we made the following conclusions. 1.
2.
The presence of dehiscence in patients affected by BCLP was significantly more common in the maxillary (61.11%) and mandibular (48.41%) anterior teeth, when compared with those of controls (7.78% and 16.67%, respectively) (P \ 0.001). The presence of fenestration was statistically significantly higher in the maxillary central incisors of the BCLP group (P\ 0.05), whereas almost similar rates were noted for the other teeth, with no statistically significant differences (P . 0.05).
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in vitro study on native pig and human mandibles. J Periodontol 2005;76:665-73. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral direct digital imaging devices: NewTom cone beam CT and Orthophos Plus DS panoramic unit. Dentomaxillofac Radiol 2003;32:229-34. Celikoglu M, Nur M, Kilkis D, Sezgin OS, Bayram M. Mesiodistal tooth dimensions and anterior and overall Bolton ratios evaluated by cone beam computed tomography. Aust Orthod J 2013;29: 153-8. Rupprecht RD, Horning GM, Nicoll BK, Cohen ME. Prevalence of dehiscences and fenestrations in modern American skulls. J Periodontol 2001;72:722-9. Larato DC. Alveolar plate fenestrations and dehiscences of the human skull. Oral Surg Oral Med Oral Pathol 1970;29:816-9. Edel A. Alveolar bone fenestrations and dehiscences in dry Bedouin jaws. J Clin Periodontol 1981;8:491-9. Abdelmalek RG, Bissada NF. Incidence and distribution of alveolar bony dehiscence and fenestration in dry human Egyptian jaws. J Periodontol 1973;44:586-8. Zhou L, Li WR. Evaluation of alveolar bone defects on anterior region in patients with bimaxillary protrusion by using cone-beam CT. Beijing Da Xue Xue Bao 2015;47:514-20. Garib DG, Yatabe MS, Ozawa TO, Filho OG. Alveolar bone morphology in patients with bilateral complete cleft lip and palate in the mixed dentition: cone beam computed tomography evaluation. Cleft Palate Craniofac J 2012;49:208-14. Rasko Z, Nagy L, Radnai M, Piffko J, Barath Z. Assessing the accuracy of cone-beam computerized tomography in measuring thinning oral and buccal bone. J Oral Implantol 2016;42:311-4.
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Evaluation of dehiscence and fenestration in adolescents affected by bilateral cleft lip and palate using cone-beam computed tomography Mevlut Celikoglu,a Suleyman Kutalmis Buyuk,b Mukerrem Hatipoglu,c Ahmet Ercan Sekerci,d and Mehmet Ertugrul Ciftcie Antalya, Ordu, and Kayseri, Turkey
Introduction: We evaluated the dehiscence and fenestration presence in maxillary and mandibular anterior teeth of patients affected by bilateral cleft lip and palate (BCLP) and compared the findings with a well-matched control group of noncleft patients using cone-beam computed tomography. Methods: Conebeam computed tomography images of 51 patients were divided into 2 groups (group 1, 21 patients affected by BCLP; mean age; 14.62 6 2.89 years; and group 2, 30 patients as the noncleft control group; mean age, 14.22 6 1.05 years) and assessed them for dehiscence and fenestration in the anterior maxillary and mandibular teeth. Data were analyzed with the Student t test, Pearson chi-square test, and Fischer exact test. Results: The prevalences of dehiscence in patients affected by BCLP were 61.11% in the maxillary and 48.41% in the mandibular anterior teeth, whereas the rates in the noncleft group were 7.78% and 16.67%, respectively (P \ 0.001). The presence of fenestration was found to be statistically significantly higher in the maxillary central incisors of the BCLP group compared with the noncleft controls (P\0.05), and almost similar rates were noted for the other teeth, with no statistically significant differences (P . 0.05). Conclusions: Our data suggest that patients affected by BCLP may have higher prevalences of dehiscence in the maxillary and mandibular anterior teeth and of fenestration in the maxillary central incisors. (Am J Orthod Dentofacial Orthop 2017;152:458-64)
C
left lip and palate (CLP) is a common craniofacial birth defect; several reasons, including genetic and environmental factors, may be responsible for the etiology and pathogenesis of this congenital malformation.1-3 Patients affected by CLP have complaints of mouth breathing, snoring, and hypopnea during sleep, and also have feeding, speaking, hearing, and esthetic
a Department of Orthodontics, Faculty of Dentistry, Akdeniz University, Antalya, Turkey. b Department of Orthodontics, Faculty of Dentistry, Ordu University, Ordu, Turkey. c Department of Periodontology, Faculty of Dentistry, Akdeniz University, Antalya, Turkey. d Private practice, Kayseri, Turkey. e Private practice, Antalya, Turkey. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Mevlut Celikoglu, Department of Orthodontics, Faculty of Dentistry, Akdeniz University, Dumlupianar Bulvari, Antalya, Turkey 07058; e-mail, [email protected]. Submitted, June 2016; revised and accepted, January 2017. 0889-5406/$36.00 Ó 2017 by the American Association of Orthodontists. All rights reserved. http://dx.doi.org/10.1016/j.ajodo.2017.01.024
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problems.4-6 Previous studies investigating the craniofacial development of these patients reported that anterior and posterior crossbite, midface deficiency with a tendency toward a Class III malocclusion, increased vertical dimensions, and decreased pharyngeal airway volume were commonly seen with this deformity.5-9 In addition, these patients were reported to be at risk for the development of periodontitis and mucogingival problems.10 Salvi et al11 reported a high incidence of plaque and bleeding on probing and a high level of periodontal attachment loss in these patients. Ercan et al12 reported reduced bone support that may cause some problems during orthodontic treatment at teeth near the cleft region compared with the noncleft region. Reduced alveolar support of the teeth might be a complicating factor during orthodontic treatment, and there is an increased risk of exacerbating or creating alveolar defects including dehiscence and fenestration.13 Although some studies investigated dehiscence and fenestration in patients with different sagittal and vertical malocclusions, it was almost neglected for the
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Table I. Criteria for sample selection Inclusion criteria BCLP Complete BCLP group Surgical closure of the lip and palate before the age of 3 years Good quality images Control Normal healthy group subjects Good quality images
Exclusion criteria Previous orthodontic (fixed or removable appliances) and prosthodontic treatment History of trauma Previous orthognathic surgery Cleft presence Syndrome presence Previous orthodontic and prosthodontic treatment History of trauma Previous orthognathic surgery
patients affected by CLP.14-16 Buyuk et al17 evaluated dehiscence and fenestration in the maxillary anterior teeth of patients affected by unilateral CLP (UCLP) using cone-beam computed tomography (CBCT) and reported that those patients had statistically significantly higher prevalences of dehiscences on the maxillary central and lateral incisors and canines, and a higher prevalence of fenestrations on the maxillary central incisors compared with noncleft patients. No previous study has evaluated the alveolar defects of dehiscence and fenestration in adolescent patients affected by bilateral CLP (BCLP). Thus, the aim of this study was to evaluate the dehiscences and fenestrations in maxillary and mandibular anterior teeth of patients affected by BCLP using CBCT. MATERIAL AND METHODS
We used the CBCT images that were part of the diagnostic records collected for dental and orthodontic treatment needs (presence of CLP, localization of impacted third molar before surgical extraction, pharyngeal airway assessment, and temporomandibular disorders) at Erciyes University in Kayseri, Turkey; no CBCTs were taken for the purpose of this study. The study was approved by the ethical committee of the same university. A power analysis was performed as described by Pandis and Machin,18 based on a significance level of 0.05 and a power of 80% to detect a clinically meaningful difference of 30% for the presence of dehiscence in maxillary central incisors between the groups using the findings of Buyuk et al,17 who reported statistically significant differences for patients affected by UCLP compared with noncleft controls (43% and 13%, respectively). Power analysis showed that 49 patients were needed for the study. According to the inclusion and exclusion criteria (Table I), the CBCT images of 51 patients were divided into 2 groups: group 1 consisted of 21 patients (3 girls,
18 boys; mean age, 14.62 6 2.89 years) affected by BCLP and group 2 consisted of 30 patients (8 girls, 22 boys; mean age, 14.22 6 1.05 years) as the control group without clefts. The patients affected by BCLP had no previous orthodontic treatment (fixed or removable appliances), and their CLP were surgically operated before the age of 3 years (Table I). All images had been obtained in standard operating conditions (CBCT scanning time, 18 seconds; collimation height, 13 cm; exposure time, 3.6 seconds; slice thickness, 0.25 mm; voxel size, 0.15 mm; and supine position) using the same machine (5G, QR; NewTom, Verona, Italy). Each 3-dimensional (3D) rendered image was reoriented using the Frankfort horizontal plane as the horizontal reference plane, constructed from the right and left porions, which are located in the most laterosuperior point of the external auditory meatus and the right and left orbitale, the most inferior point of the lower margin of the bony orbit. The sagittal reference plane was constructed from nasion and the midorbital point, perpendicular to the horizontal reference plane. The axial plane was constructed from nasion, perpendicular to the horizontal and sagittal planes. The images were transformed to DICOM format, and Simplant Pro software (version 16.0; Materialise, Leuven, Belgium) was used to evaluate the presence of dehiscences and fenestrations in the roots of maxillary and mandibular anterior teeth using the sagittal and axial slices at the buccal and lingual surfaces. Buccal and lingual surfaces of all maxillary and mandibular anterior teeth in the study (21 patients, 216 teeth) and control (30 patients, 360 teeth) were evaluated. It was classified as dehiscence when the alveolar bone height was more than 2 mm from the cementoenamel junction (Fig 1). When the defect did not involve the alveolar crest, it was classified as fenestration (Fig 2).19 All evaluations for dehiscence and fenestration were done by an experienced orthodontist (S.K.B.), who was previously trained for the study in random order without knowing the patients' groups. In addition, the same orthodontist assessed the sagittal and vertical growth patterns of the patients using ANB (1 \Class I \ 5 ; Class II . 5 ; Class III \1 )20 and SN-MP (high-angle group, .38 ; low-angle group, \26 ; normal-angle group, 26 –38 )21,22 parameters in both study and control groups with 3D cephalometry. Statistical analysis
To determine the random error, 20 CBCT images were randomly selected. All evaluations were blindly done 4 weeks after the first examination by the same orthodontist (S.K.B.). No difference was found for the presence of dehiscence and fenestration in the randomly
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Fig 1. Sagittal cross-sectional views of dehiscence (arrows) in the maxilla.
Fig 2. Sagittal cross-sectional views of fenestration (arrows) in the maxilla.
selected images, showing 100% agreement between the 2 readings. In addition, an experienced radiologist (A.E.S.) confirmed the agreement of the alveolar defect presence (100% agreement). The same author (S.K.B.) measured the ANB and SN-MP parameters, and the reliability of those measurements was tested with the Houston test.23 Statistical comparisons of alveolar defect prevalence and chronologic age distribution were done using the Pearson chi-square and Student t tests, respectively. Comparison of sex distributions between the groups was done using the Fisher exact test. All statistical analyses were performed using the SPSS software package for Windows (version 15.0; SPSS, Chicago, Ill), and P \ 0.05 was considered statistically significant. RESULTS
Intraexaminer and interexaminer reliability scores were 100% for the assessment of both dehiscence and fenestration. The Houston test23 confirmed the reliability of those measurements showing the growth patterns of the patients (r . 0.952). The comparisons of the chronologic ages (14.62 6 2.89 and 14.22 6 1.05 years, respectively) and sex distribution (female/male, 3/18 and 8/22, respectively) between the cleft and control groups showed that the groups were well matched according to the Student t and Pearson chi-square tests
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(P . 0.05). Most patients in the BCLP group had skeletal Class III malocclusions (10 patients) and low-angle growth patterns (9 patients), whereas the patients in the control group commonly had Class I malocclusions (26 patients) and normal-angle (27 patients) growth patterns (Table II). Statistical comparisons showed significant differences for both maxillary and mandibular anterior teeth between the BCLP and the control groups (P \ 0.001). Dehiscences were observed in 76.19% (32 of 42 teeth), 50.0% (3 of 6 teeth), and 47.62% (20 of 42 teeth) of the maxillary central incisors, lateral incisors, and canines, respectively. Those rates were statistically significantly higher compared with those of the noncleft controls (13.33%, 6.67%, and 3.34%, respectively) (P \ 0.001) (Table III). The BCLP group had statistically significantly high values for the mandibular central incisors (28 of 42 teeth; 66.67%), lateral incisors (18 of 42 teeth; 42.86%), and canines (15 of 42 teeth; 35.71%) compared with those of the noncleft controls (38.33%, 10.0%, and 1.67%, respectively). Dehiscence was commonly observed in both surfaces (28/55; 50.9%) of the maxillary anterior teeth, whereas it was more predominant in the buccal surface (35/61; 57.4%) of the mandibular anterior teeth in the BCLP group. On the other hand, it was more predominant in the lingual surfaces of the maxillary (13/14; 92.9%) and mandibular (25/30; 83.3%) anterior teeth in the control group.
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Table II. Distribution of chronologic ages, sexes, and growth patterns of the groups
BCLP group (n 5 21) Control group (n 5 30) P
Mean age (y) 14.62 6 2.89 14.22 6 1.05 0.555*
Female/Male 3/18 8/22 0.318y
Sagittal growth pattern
Vertical growth pattern
Class I/Class II/Class III 2/9/10 26/4/0
H-A/L-A/N-A 5/9/7 1/2/27
H-A, High angle; L-A, low angle; N-A, normal angle. *Results of Student t test; yresults of Fisher exact test.
Table III. Comparison of the dehiscence prevalence between the BCLP and control groups
Tooth type Maxillary central incisor Maxillary lateral incisor Maxillary canine Total Mandibular central incisor Mandibular lateral incisor Mandibular canine Total
BCLP group
Control group
Dehiscence presence
Dehiscence presence
Yes (%) 32/42 (76.19) 3/6 (50.0) 20/42 (47.62) 55/90 (61.11) 28/42 (66.67) 18/42 (42.86) 15/42 (35.71) 61/126 (48.41)
No (%) 10/42 (23.81) 3/6 (50.0) 22/42 (52.18) 35/90 (38.89) 14/42 (33.33) 24/42 (57.14) 27/42 (64.29) 65/126 (51.59)
Yes (%) 8/60 (13.33) 4/60 (6.67) 2/60 (3.34) 14/180 (7.78) 23/60 (38.33) 6/60 (10.0) 1/60 (1.67) 30/180 (16.67)
No (%) 52/60 (66.67) 56/60 (93.33) 58/60 (66.66) 166/180 (92.22) 37/60 (51.67) 54/60 (90.0) 59/60 (100.0) 150/180 (83.33)
P* 0.000 0.000 0.000 0.000 0.004 0.000 0.000 0.000
*Results of Pearson chi-square test.
Comparison of the fenestration prevalence between the BCLP and control groups showed that the BCLP group had statistically significantly higher values at the maxillary central incisors (5/42; 11.9%) compared with the noncleft control group (1/60; 1.67%) (P \ 0.05). Similar values were found for the other teeth in both groups with no statistically significant differences (P . 0.05) (Table IV). Fenestration was more predominant on the buccal surface of the maxillary anterior teeth (4/7; 57.14%) and was observed on the buccal surface of all mandibular anterior teeth in the BCLP group (4/4; 100%), and on all maxillary (6/6; 100%) and mandibular (6/6; 100%) anterior teeth in the control group. DISCUSSION
Previous studies have shown that alveolar dehiscence and fenestration are common in different types of malocclusions.14-16,24-26 The presence of those alveolar defects might cause gingival recession and additional bone loss during orthodontic treatment and thus greater potential for treatment relapse26,27 or unesthetic orthodontic treatment finishing.28,29 Since cleft patients have been reported to have several dental and skeletal malocclusions, it is important to detect their alveolar defects to perform a well-planned and organized orthodontic therapy.5,6,30,31 However, the
investigations of alveolar dehiscence and fenestration in patients affected by BCLP have been almost neglected in the literature; thus, this retrospective study was performed to present important findings about alveolar defects in BCLP patients. CBCT images were used to assess alveolar dehiscence and fenestration, since this technology has the potential to identify those defects without the disadvantages that are common in conventional radiographs.32-34 This technology is reported to be an important option for many clinical dental situations because of better image resolution, lower dose of radiation, and lower costs compared with multislice computed tomography.33,35 Therefore, the CBCT images obtained from the archive were used for this study. Intraexaminer and interexaminer reliability scores confirmed the excellent reproducibility and reliability of the CBCT images for assessment of the measurements performed in our study, as reported in previous studies.12,17,36 Buyuk et al17 reported 100% agreement of the CBCT images when used for the assessment of alveolar defects. Previous studies reported different values for dehiscence and fenestration in the teeth of various ethnic groups, ranging from 0.99% to 13.4% and from 0.23% to 16.9%, respectively.37-40 Increased prevalences of dehiscence and fenestration was
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Table IV. Comparison of fenestration prevalence between the BCLP and control groups
Tooth type Maxillary central incisor Maxillary lateral incisor Maxillary canine Total Mandibular central incisor Mandibular lateral incisor Mandibular canine Total
BCLP group
Control group
Fenestration presence
Fenestration presence
Yes (%) 5/42 (11.9) 1/6 (16.67) 1/42 (2.38) 7/90 (7.78) 3/42 (7.14) 1/42 (2.38) 0/42 (0.0) 4/126 (3.17)
No (%) 37/42 (97.62) 5/6 (83.33) 41/42 (97.62) 83/90 (92.22) 39/42 (92.86) 41/42 (97.62) 42/42 (100.0) 122/126 (96.83)
Yes (%) 1/60 (1.67) 3/60 (5.0) 2/60 (3.33) 6/180 (3.33) 3/60 (5.0) 2/60 (3.33) 1/60 (1.67) 6/180 (3.33)
No (%) 59/60 (98.33) 57/60 (95.0) 58/60 (3.33) 174/180 (96.67) 57/60 (95.0) 58/60 (96.67) 59/60 (98.33) 174/180 (96.67)
P* 0.031 0.253 0.779 0.108 0.651 0.779 0.401 0.939
*Results of Pearson chi-square test.
reported in different sagittal and vertical malocclusions using CBCT.14-16,25 Sun et al25 reported that the prevalence of dehiscence was 61.57% in teeth, and the rate was 31.93% for fenestration in patients with skeletal Class III malocclusions. Increased rates of alveolar defects were also reported for the bimaxillary protrusion malocclusion.41 In the study of Evangelista et al,14 the prevalence of dehiscence (51.09%) was higher than that of fenestration (36.51%), and more frequent in Class I malocclusions compared with Class II Division 1 malocclusions. Several factors may have effects on these different rates of alveolar defects including ethnic differences, dental and skeletal malocclusions, increased or decreased inclination of the teeth, crowding, decreased buccal or lingual cortical bone thickness, and visualization of the periodontal ligament.14,37 In this study, the prevalence of dehiscence in patients affected by BCLP was 61.11% in the maxillary and 48.41% in the mandibular anterior teeth, whereas the rates in the noncleft group were 7.78% and 16.67%, respectively. Previous studies reported that patients affected by BCLP had retruded maxillae and mandibles, decreased maxillary and mandibular lengths, increased vertical growth patterns, and decreased maxillary and mandibular incisors compared with the noncleft controls.6,8 Increased rates of both dehiscence and fenestration in BCLP patients might be associated with their skeletal and dental characteristics. It might occur because of decreased cortical bone thickness of the maxillary anterior teeth near the cleft area as stated by Ercan et al.12 Garip et al42 reported that the teeth adjacent to an alveolar cleft are covered by a thin alveolar bone plate and a slight increase in the distance between the alveolar bone crest and the cementoenamel junction in the mesial and lingual aspects of canines adjacent to the cleft. The decreased bony support of those teeth might play a role for the alveolar defects. Another cause
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for increased defects might be the potential differences in socioeconomic status of the groups that could not be assessed in this study because of its retrospective design. A unique study assessed dehiscences and fenestrations in UCLP patients using CBCT but did not assess the mandibular teeth; the authors reported that maxillary anterior teeth in both cleft and noncleft sides had significantly higher rates of dehiscence compared with the noncleft group.17 Our findings for maxillary anterior teeth agreed with those of Buyuk et al.17 In addition to that finding, we found significantly higher dehiscence prevalence in the mandibular anterior teeth (central incisors, 66.67%; lateral incisors, 42.86%; and canines, 35.71%) compared with the noncleft group (central incisors, 38.33%; lateral incisors, 10.0%; and canines, 1.67%) (P \ 0.01). In contrast to the literature14-16,38 showing that fenestration was more common in the maxillary teeth, our study showed that it was similar in both arches of the noncleft group. The presence of fenestration was statistically significantly higher in the maxillary central incisors of the BCLP group (P \ 0.05), whereas almost similar rates were noted for the other teeth, with no statistically significant differences. This finding agrees with that of Buyuk et al17 reported for UCLP patients. The findings of patients affected by BCLP with a higher prevalence of alveolar defects in the maxillary and mandibular anterior teeth motivate us to caution clinicians to treat patients affected by CLP carefully during their orthodontic treatment. Clinicians who treat those patients should get a CBCT image before their orthodontic treatment, assess the teeth for dehiscence and fenestration, and plan the tooth movement in teeth with alveolar defects. On the other hand, our retrospective study had limitations because of its design. One limitation of the study
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was that the periodontal health of the patients in both groups could not be assessed clinically. The differences in periodontal health between the groups might have affected our findings. Further clinical studies are needed to evaluate the relationship of alveolar bone defects and periodontal problems. Another limitation was that the CBCT images used in this study were taken with 0.25mm slices that might be questionable to detect thin bone layers that are normally present in the anterior dental region.43 Future studies using less than 0.20 mm might be welcome to discuss and compare our findings. A limited number of study samples for the BCLP group is another concern. CONCLUSIONS
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8.
9.
10.
11.
12.
Within the limitations of this retrospective study, we made the following conclusions. 1.
2.
The presence of dehiscence in patients affected by BCLP was significantly more common in the maxillary (61.11%) and mandibular (48.41%) anterior teeth, when compared with those of controls (7.78% and 16.67%, respectively) (P \ 0.001). The presence of fenestration was statistically significantly higher in the maxillary central incisors of the BCLP group (P\ 0.05), whereas almost similar rates were noted for the other teeth, with no statistically significant differences (P . 0.05).
13.
14.
15.
16.
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