UNIVERSITY OF MEDICINE AND PHARMACY GR. T. POPA - IASI FACULTY OF DENTAL MEDICINE ABSTRACT CONTRIBUTIONS OF THREE-DIMENSIONAL IMAGING TO THE DIAGNOSIS AND MANAGEMENT OF CLEFT LIP AND PALATE PhD ADVISOR, PROF. UNIV. DR. DANISIA HABA PhD CANDIDATE, ANA BAMBOI IASI 2015
CONTRIBUTION OF THREE-DIMENSIONAL IMAGING TO THE DIAGNOSIS AND TREATMENT OF CLEFT LIP AND PALATE ABSTRACT CHAPTER 5 MOTIVATION AND OBJECTIVES OF THE Ph-D STUDY Patients with cleft lip and palate (CL/P) undergo treatment for a long period of time. Starting from childhood and until the adult years, they are submitted to numerous treatments from multidisciplinary teams of specialists. Surgical interventions are necessary to rebuild the anatomy of the dental arches, of the face, and to reestablish the function of the palate, muscles of the lips and nose. Therefore, the aims of this Ph-D study were: 1) Achieving an experimental study on a dried skull to demonstrate the applicability of CBCT and of the Romexis program to determine the actual volume of bone defects in the cleft lip and palate patients and to establish a protocol for image processing that will allow this analysis. 2) Achieving a study whose aim is to assess the volume of pharyngeal airways three-dimensionally on patients with cleft lip and palate and to compare it with a control group. 3) A study which aims to analyze three-dimensionally the volume of the maxillary sinus in cleft lip and palate patients 1
and to compare it with a control group. This study aimed to compare also the volume of the affected maxillary sinus with that of the healthy one. 4) To undertake a study that evaluates anatomical variations and pathological changes in the anatomy of CL/P patients with the help of CBCT. 5) Achieving a study that will morphometrically assess the mandible and the TMJ in patients with CL/P. CHAPTER 6 CBCT EVALUATION OF ALVEOLAR BONE DEFFECT IN PATIENTS WITH UNILATERAL CLEFT LIP AND PALATE - EXPERIMENTAL STUDY 6.1 INTRODUCTION The aim of this study was to determine the applicability of CBCT exams to determine the actual volume of alveolar bone defects on a dried skull and to establish a protocol that will allow image processing for this analysis. 6.2 MATHERIALS AND METHODS A dried skull was scanned using CBCT, multiple times, using different examination protocols. The CBCT equipment used was PlanmecaPromax 3D Mid (Planmeca OY, Helsinki, Finland). All CBCT images were analysed independently by 3 different examiners: a specialist in Oral and Maxillofacial Radiology, a specialist in Orthodontics and Dento-Facial Orthopedics and a specialist in Oral and Maxillofacial Surgery. The results were compared for each protocol. 2
6.3 RESULTS The results of the analysis have proved a better correlation between the measurements of the orthodontics specialist and the maxillofacial surgeon (r=0.95, p<<0.001). Relating to the actual value of the volume graft (0.0118) we could appreciate that the surgeon approaches best to this value, whereas the radiologist and the orthodontist show a similarity in assessing the volume. 6.4 DISCUTIONS The results of this study found a reliability of 99 %, compared to the gold standard. This shows that the assessment of volumetric bone defects in cleft lip and palate patients is quite reliable when high resolution CBCT scans are performed. CHAPTER 7 CBCT EVALUATION OF THE MAXILLARY SINUS VOLUMES ON CLEFT LIP AND PALATE PATIENTS 7.1 INTRODUCTION This study was realized to determine if the dimensions of the pharyngeal airways and the maxillary sinuses differ between growing patients with cleft lip and palate. 7.2 MATHERIALS AND METHODS The study group consisted of 21 patients with cleft lip and palate. 4 were excluded due to the presence of 3
maxillary sinusitis, and 2 due to tonsillar hypertrophy. The control group was made of 12 patients with the same age and dentition as the study group. All CBCT images were analysed independently by 3 different examiners: a specialist in Oral and Maxillofacial Radiology, a specialist in Orthodontics and Dento-Facial Orthopedics and a specialist in Oral and Maxillofacial Surgery. 7.3 RESULTS Results have indicated significantly lower values for the right maxillary sinus for the CL/P group compared to the left maxillary sinus (p=0.046). 7.4 DISCUTIONS The volume of the pharyngeal airways was significantly higher in the control group of adolescence than in that of children, and also higher in the control group compared to the CL/P group. CHAPTER 8 CBCT ASSESSMENT OF ANATOMICAL VARIATIONS OF THE VISCEROCRANIUM IN CLEFT LIP AND PALATE PATIENTS 8.1 INTRODUCTION The aim of this study was to determine the existence of incidental findings in patients with CL/P on CBCT images. The information will be useful in developing regulations for the interpretation of CBCT scans in a patient with DLMP. 4
8.2 MATHERIALS AND METHODS The study group consisted of 21 patients with cleft lip and palate. 2 were excluded due to the presence of bilateral cleft lip and palate. The CBCT equipment used was PlanmecaPromax 3D Mid (Planmeca OY, Helsinki, Finland). All CBCT images were analysed by one examiner: a specialist in Orthodontics and Dento-Facial Orthopedics.. The results were compared and analyzed statisticallyl. 8.3 RESULTS Analyzing the variables on sex groups, there was a statistically significant difference between men and women regarding the cleft volume ( p = 0.028 ). Men presented a higher volume ( average 1.31 ± 0.316 ± 0.320 compared to 0.760 the volume for women). 8.4 DISCUTIONS The results of CBCT analysis of CL/P patients showed that most scans were used in the dental field. CHAPTER 9 CBCT EVALUATION OF THE MANDIBLE AND THE TEMPORO-MANDIBULAR JOINT ON PATIENTS WITH CLEFT LIP AND PALATE 9.1 INTRODUCTION To evaluate minor facial asymmetries, in the present study, we have evaluated the chin deviation on patients with cleft lip and palate. We have assessed the factors that contribute to this deviation. Mostly, we ve built three-dimensional images using CBCT and measured the position and shape of the 5
mandible and TMJ, that are tightly associated with the chin deviation. 9.2 MATHERIALS AND METHODS The study group consisted of 21 patients with cleft lip and palate. 2 were excluded due to the presence of bilateral cleft lip and palate. The reference planes (horizontal, sagittal and coronal) were established initially. All CBCT images were analysed independently by 3 different examiners: a specialist in Oral and Maxillofacial Radiology, a specialist in Orthodontics and Dento-Facial Orthopedics and a specialist in Oral and Maxillofacial Surgery. 9.3 RESULTS The results indicate the fact that the values for chin deviation to the right or left, the width of the left condyle, the length of the horizontal right ramus, the depth of the left glenoid cavity, the widths of the right condyle and the depth of the right glenoid cavity show significant differences when the cleft is located on the right or left side. CHAPTER 10 GENERAL CONCLUSIONS 1. This study is a complex imaging study analyzing the efficiency of three-dimensional CBCT imaging investigations, which is used in orthodontic and surgical treatment planning of patients with cleft lip and palate. 2. The research in this thesis is focused on several directions of investigation 3. CBCT is one of the most modern imaging technique which brings a lot of information about the three- 6
dimensional structure of the face for planning facial surgery in patients with cleft lip and palate. It provides a low-dose irradiation. 4. The prevalence of incidental findings on CBCT is three times higher in patients with CL/P compared to healthy subjects. 7