Two- or three-dimensional cast analysis in patients with cleft lip and palate?

Maxillary arch dimensions in bilateral cleft lip and palate in the age 0-5 months

INTRODUCTION

The complete bilateral cleft lip and palate (BCLP) divides the maxillary arch into three segments, separated from each other, resulting in abnormal growth of the alveolar arch. This study evaluated the maxillary arch dimensions in BCLP and compared them with neonates without craniofacial anomalies.

METHODS

This retrospective study was conducted in a tertiary cleft centre. Sixty-six neonates aged 0-5 months were divided into two groups: cleft group-children with BCLP (23 boys and 18 girls) and control group-children without craniofacial deformities (15 boys and 10 girls). The dental models were processed by a 3D scanner. Landmarks were marked to achieve inter-canine distance, inter-tuberosity distance and arch length measurements. t-Tests were used for intergroup comparisons (p < .05).

RESULTS

The maxillary cleft arch was demonstrated to be wider and longer in the posterior region compared to the control group. The inter-canine distance did not present differences between the cleft and controls. The inter-canine distance of the control group was the only measurement influenced by the variable sex.

CONCLUSIONS

The cleft significantly interfered with the arch posterior width and arch sagittal length, making them larger. There was no statistical difference in the measurements between sex in the cleft group.

Evaluation of maxillary arch symmetry in cleft patients undergoing orthodontic treatment: a comparative study

OBJECTIVE

Patients with a cleft require structured procedures to achieve feasible treatment results. Since many treatment protocols coexist without being superior to one another, this study investigated the Saarland University Hospital treatment concept for patients with unilateral and bilateral clefts to evaluate its effects upon dental arch dimensions until the early mixed dentition.

MATERIAL AND METHODS

Digitized plaster models were used for data collection. Records of 83 patients (Cleft n = 41 [UCLP n = 28, BCLP n = 13], Non-Cleft Control n = 42) comprised 249 casts. The evaluation included established procedures for measurements of edentulous and dentate jaws. Statistics included Shapiro-Wilk, Friedmann, Wilcoxon and Mann-Whitney-U-Tests for the casts. The level of significance was set at p < 0.05.

RESULTS

The cast analysis showed an approximation of arch dimensions towards those of age-matched patients without a cleft until early mixed dentition. The mean values of patients with and without cleft lip and palate were almost indistinguishable when compared in primary and/or early mixed dentition.

CONCLUSIONS

The evaluated treatment concept leads to feasible outcomes regarding dental arches in patients with unilateral and bilateral clefts compared to an age-matched non-cleft control.

CLINICAL RELEVANCE

The evaluated treatment concept leads to favorable outcomes until early mixed dentition.

Three-dimensional Analysis of Maxillary Morphology in Infants with Unilateral Cleft Lip and Palate

OBJECTIVE

To three-dimensionally (3D) analyze the maxillary morphology of infants with unilateral cleft lip and palate (UCLP) and preliminarily classify the alveolar arch to assist in personalization of sequence therapy.

DESIGN

Retrospective study.

SETTING

Patients with UCLP referred to outpatients' clinic.

PARTICIPANTS

84 nonsyndromic infants with complete UCLP were recruited (58 boys, 26 girls, mean age 29.48 days).

MAIN OUTCOME MEASURE

Morphometric analysis was conducted on 3D maxillary models. Principal component analysis (PCA) and cluster analysis were combined to classify maxillary phenotypes preliminarily. The Wilcoxon Signed Rank test and the Kruskal-Wallis test were used to compare differences between variables. A P value less than .05 was considered statistically significant.

RESULTS

The maxilla was divided into three types: narrow, homogenous and broad, accounting for 9.52%, 23.81% and 66.67% respectively. The alveolar cleft site (median value) was located in 61% of the total length of the alveolar arch. In the comparison of anterior and total alveolar lengths, the non-cleft side had longer alveolar bone than the affected side, a difference of approximately 2 mm. Pairwise comparisons of variables describing alveolar symmetry revealed significant differences in all subjects; whereas type C had poorer arch symmetry than types A and B, mainly in terms of anterior and overall symmetry.

CONCLUSIONS

In infants with UCLP, the maxillary alveolar arch was inherently asymmetrical with partially bone missing (about 2 mm). Significant differences in alveolar bone morphology and symmetry exist between different types of infants, with individuals with broad clefts (type C, the largest proportion) having the worst maxillary development.

Three-dimensional evaluation of alveolar changes induced by nasoalveolar molding in infants with unilateral cleft lip and palate: A case-control study

OBJECTIVE

The objectives of this study were to evaluate linear and volumetric alveolar changes induced by nasoalveolar molding (NAM) in infants with complete unilateral cleft lip and palate (UCLP) and compare the maxillary dimensions after NAM with the normal dimensions in infants without clefts.

METHODS

A total of 26 infants with UCLP treated by NAM (mean age before and after NAM: 14.20 ± 8.09 days and 118.16 ± 10.06 days, respectively) comprised the treatment group, while 26 infants without clefts (mean age: 115.81 ± 8.71 days) comprised the control group. Changes in the maxillary dimensions following NAM were measured on three-dimensional models using Mimics software, version 17.0.

RESULTS

During NAM, there was a decrease in the cleft widths, maxillary arch depths, and rotation of the greater segment. While the anterior alveolar arch width exhibited a significant decrease, the posterior arch width was mostly maintained. There were no changes in the anterior vertical deviations of the alveolar segments. The alveolar crest lengths, arch circumference, and bilateral posterior volumetric measures exhibited an increase. After NAM, the anterior arch width was comparable between the treatment and control groups, whereas the posterior arch width and anterior vertical deviations were greater in the treatment group than in the control group. The maxillary arch depths, alveolar crest lengths, and maxillary volumes were smaller in the NAM group than in the control group.

CONCLUSIONS

During NAM in infants with UCLP, the cleft width and anteroposterior and transverse alveolar dimensions exhibited a decrease while the vertical dimensions were maintained. Compared with infants without clefts, those with UCLP treated by NAM exhibited sagittal and vertical alveolar growth deficiencies and tissue insufficiency.

Dimensional accuracy of jaw scans performed on alginate impressions or stone models: A practice-oriented study

OBJECTIVES

Digital jaw models offer more extensive possibilities for analysis than casts and make it easier to share and archive relevant information. The aim of this study was to compare the dimensional accuracy of scans performed on alginate impressions and on stone models to reference scans performed on underlying resin models.

METHODS

Precision spheres 5 mm in diameter were occlusally fitted to the sites of the first premolars and first molars on a pair of jaw models fabricated from resin. A structured-light scanner was used for digitization. Once the two reference models had been scanned, alginate impressions were taken and scanned after no later than 1 h. A third series of scans was performed on type III stone models derived from the impressions. All scans were analyzed by performing five repeated measurements to determine the distances between the various sphere centers.

RESULTS

Compared to the reference scans, the stone-model scans were larger by a mean of 73.6 µm (maxilla) or 65.2 µm (mandible). The impression scans were only larger by 7.7 µm (maxilla) or smaller by 0.7 µm (mandible). Median standard deviations over the five repeated measurements of 1.0 µm for the reference scans, 2.35 µm for the impression scans, and 2.0 µm for the stone-model scans indicate that the values measured in this study were adequately reproducible.

CONCLUSION

Alginate impressions can be suitably digitized by structured-light scanning and offer considerably better dimensional accuracy than stone models. Apparently, however, both impression scans and stone-model scans can offer adequate precision for orthodontic purposes. The main issue of impression scans (which is incomplete representation of model surfaces) is being systematically explored in a follow-up study.

Multibracket appliance: impression defaults and their reduction by blocking-out - a three-dimensional study

OBJECTIVES

This study examines accuracy of dental impressions and following plaster models taken during treatment with fixed appliances.

MATERIALS AND METHODS

A maxillary typodont was provided with brackets. Three examiners took impressions three times each of the variants: brackets only, archwire fixed by alastics, ligatures or Kobayashi-hooks, and brackets and archwire covered completely or just on the gingival side by protection or impression wax. Casts were scanned using Activity102(®). Virtual models were compared to the scan of the typodont using Comparison(®). Differences were measured and descriptively analyzed. Estimated means with 95% confidence intervals were computed. Significance was assessed using linear mixed models.

RESULTS

While pyramidal reference blocks had a mean difference of 0.019 mm (95% CI = 0.017-0.021 mm) to the master model, teeth without attachments showed 0.097 mm (95% CI = 0.082-0.111 mm), and teeth with brackets 0.169 mm (95% CI = 0.156-0.182 mm) (p < 0.001). Smallest mean was found when using protection wax only on the gingival bracket side (0.152 mm (95% CI = 0.113-0.192 mm)). Incisors deviated most (0.258 mm (95 % CI = 0.239-0.277 mm)).

CONCLUSIONS

Teeth with brackets make impressions more inaccurate because of undercuts. Removing the archwire before taking the impression or covering the brackets on the gingival side shows tendencies toward better precision.

CLINICAL RELEVANCE

Taking impressions during treatment with fixed appliances, some inaccuracy has to be taken into account.

Critical analysis of consecutive unilateral cleft lip repairs: determining ideal sample size

Objective : Cleft surgeons often show 10 consecutive lip repairs to reduce presentation bias, however the validity remains unknown. The purpose of this study is to determine the number of consecutive cases that represent average outcomes. Secondary objectives are to determine if outcomes correlate with cleft severity and to calculate interrater reliability. Design : Consecutive preoperative and 2-year postoperative photographs of the unilateral cleft lip-nose complex were randomized and evaluated by cleft surgeons. Parametric analysis was performed according to chronologic, consecutive order. The mean standard deviation over all raters enabled calculation of expected 95% confidence intervals around a mean tested for various sample sizes. Setting : Meeting of the American Cleft Palate-Craniofacial Association in 2009. Patients, Participants : Ten senior cleft surgeons evaluated 39 consecutive lip repairs. Main Outcome Measures : Preoperative severity and postoperative outcomes were evaluated using descriptive and quantitative scales. Results : Intraclass correlation coefficients for cleft severity and postoperative evaluations were 0.65 and 0.21, respectively. Outcomes did not correlate with cleft severity (P  =  .28). Calculations for 10 consecutive cases demonstrated wide 95% confidence intervals, spanning two points on both postoperative grading scales. Ninety-five percent confidence intervals narrowed within one qualitative grade (±0.30) and one point (±0.50) on the 10-point scale for 27 consecutive cases. Conclusions : Larger numbers of consecutive cases (n > 27) are increasingly representative of average results, but less practical in presentation format. Ten consecutive cases lack statistical support. Cleft surgeons showed low interrater reliability for postoperative assessments, which may reflect personal bias when evaluating another surgeon's results.

Three-dimensional analysis of the deciduous dentition of patients with bilateral cleft lip and palate and delayed cleft closure

OBJECTIVE

The objective of this study was to describe the three-dimensional morphology of the maxilla of patients with bilateral cleft lip and palate treated by a delayed cleft closure in the deciduous dentition. They were compared to a eugnathic control group.

PATIENTS AND METHODS

Thirty-two study casts of complete bilateral cleft lip and palate from the archive of the former Wolfgang-Rosenthal Clinic Thallwitz were scanned in three-dimensions and compared to an equally large eugnathic control group. The mean age of the study group was 4.92 years, and that of the control group 5.02 years. Dimensions were recorded using a reflex microscope according to specific landmarks.

RESULTS

The study group exhibited transversal anterior compression and posterior over-development of the dental arch. We observed conspicuously more frequent, marked inward rotation of the left lateral segment together with broadly-scattered data. We were unable to establish a correlation between the anterior and posterior dental arch widths. In the sagittal dimension, the mean position of the premaxilla was in no way different than that of the control group. Vertically we noted a difference in the level between the premaxilla and lateral segments. The premaxilla was situated significantly more caudally than the lateral segments.

CONCLUSIONS

Even when cleft palate closure is delayed, the result is maxillary constriction and vertical deviation of the cleft segments. The large individual scatter of deviations demands a greatly individualized, differentiated concept for later maxillary development.

Presurgical orthopaedic treatment of newborns with clefts – functional treatment with long-term effects

AIM

Presentation of an orthopaedic/orthodontic treatment protocol within the framework of complex rehabilitation of patients with clefts of lip, alveolus and palate. Presurgical orthopaedic treatment aims at reduction of cleft size by guiding growth and functional rehabilitation. Long-term results of maxillary development and occlusion at young adult age are reported.

PATIENTS AND METHODS

43 newborns with unilateral (19) or bilateral (24) clefts of lip, alveolus and palate were examined until their deciduous dentition was complete. In 29 patients a late follow-up was performed at age 17.3 years (mean). Maxillary dental casts were evaluated prior to and following presurgical orthopaedic treatment at the time the deciduous dentition was complete and at young adult age (2 to 5 years after termination of orthodontic treatment). Parameters were width of the alveolar and palatal cleft as well as width and length of the dental arch. In the adults occlusion was studied and the occlusal outcome was related to the therapeutical input.

RESULTS

Presurgical orthopaedic treatment reduced the cleft width by taking advantage of normal growth. At the age of 3 to 4 years the development of the upper dental arch was in line with that of non-cleft children.

CONCLUSION

Maxillary growth may be guided in almost physiological terms even in patients with a cleft of lip, alveolus and palate. Prerequisite is functional rehabilitation by means of orthopaedic treatment at age 1 to 12 months in terms of functional orthodontic therapy and a surgical protocol saving tissues with growth potential.

Nasolabial and alveolar morphology following presurgical orthopaedic treatment in complete unilateral clefts of lip, alveolus and palate

INTRODUCTION

The purpose of this study was to assess the three-dimensional (3-D) facial and alveolar morphology of patients with unilateral clefts of lip, alveolus and palate by means of a computer-aided diagnosis system.

PATIENTS AND METHODS

Maxillary orthopaedic treatment was performed using soft/hard acrylic plates (Hotz's) within 2 weeks of birth. The nasolabial and alveolar morphology of 15 patients was evaluated before orthopaedic treatment (2 weeks of age) and before cheiloplasty (3 months of age). Nasolabial form was measured using a 3-D optical scanner. Twenty-one landmarks were extracted from the data and analysed linearly and angularly. Alveolar forms were measured with a high-accuracy contact-type 3-D digitizer on plaster casts. Seven landmarks were digitized and analysed linearly and angularly.

RESULTS

Some growth was observed in the intercanthal distance, alar width, intercommissural width, and height of the lip. There was little change in the width of the cleft lip or displacement of the columella base, while the alveolar cleft narrowed.

CONCLUSION

Presurgical orthopaedics reduces cleft width and makes subsequent surgery easier.

Patterns of maxillary alveolar arch growth changes of infants with unilateral cleft lip and palate: preliminary findings

OBJECTIVE

Because of significant differences in pathomorphology at birth, it may be that a better treatment outcome prognosis exists for patients with incomplete versus complete cleft forms. Can reaction patterns be extracted from changes in maxillary dimensions of different cleft forms within the first year of life to support this hypothesis?

SUBJECTS

Chronologically consecutive casts of the maxilla (1 week and 3, 6, and 12 months of life) of 15 patients with complete unilateral cleft lip and palate (cUCLP) and 13 patients with incomplete unilateral cleft lip and palate (iUCLP). All patients were treated with passive palatal plates. Cheiloplasty was performed at 6 months of age. No primary osteoplastic surgery was carried out.

INTERVENTIONS

Following digitizing with a three-dimensional laser scanner, all cast surfaces were computer reconstructed, aligned, and superimposed. Distances between the surfaces were determined and expressed graphically. Computer-aided determination of defined maxillary dimensions was performed. The volumes of segmented surfaces were determined and compared.

RESULTS

Within the first year of life, decreased sagittal but increased transverse alveolar growth for patients with iUCLP was found. The increase in alveolar crest length in patients with iUCLP was 50% less within the first year of life than in patients with cUCLP. In the same patients, the volumes of the molar segments were, on average, larger at each registration stage and the increase in these volumes larger within the first year of life.

CONCLUSION

Conclusions regarding the direction and extent of growth cannot be drawn from the visible level of severity of the malformation.