Originl Article Three-dimensionl tooth crown size symmetry in cleft lip nd cleft plte M. Okn Akcm ; Hlise Aydemir b ; Levent Özer c ; Bern Özel d ; T. Ufuk Toygr-Memikoğlu ABSTRACT Objective: To evlute nd compre three-dimensionl tooth size symmetry in the right nd left sides of upper nd lower dentl rches in cleft lip nd plte (CLP) ptients nd to compre it with n Angle Clss I norml occlusion control group. Mterils nd Methods: Dentl csts of 72 individuls with CLP (20 bilterl [BCLP], 34 unilterl left [ULCLP], nd 18 unilterl right [URCLP]) nd 53 individuls with Clss I occlusion, ll with permnent dentition, were rndomly selected. Mesiodistl (MD), lbiolingul (LL), nd occlusogingivl (OG) mesurements of upper nd lower teeth were recorded with digitl cliper. Descriptive sttistics nd pired t-test were used for sttisticl nlysis. Results: Significnt symmetries were found between the right nd left sides of the dentl rches in CLP s follows: MD dimension: mndibulr first premolr (ULCLP, P,.01); LL dimension: mndibulr first premolr (URCLP, P,.05); OG dimension: mxillry centrl incisor nd first premolr (ULCLP, P,.05 nd P,.01, respectively), centrl incisor (BLCLP, P,.01), mndibulr cnine nd first premolr (ULCLP, P,.01), nd first molr (ULCLP, P,.05). Tooth crown size symmetries were lso recorded in the Clss I group. Conclusions: Significnt three-dimensionl tooth size symmetries were found in CLP subjects; however, such symmetries were lso present on the Clss I control group. (Angle Orthod. 2014;84:623 627.) KEY WORDS: Tooth size; Symmetry; Cleft lip nd plte INTRODUCTION Cleft lip nd plte (CLP) is one of the most common congenitl crniofcil nomlies with multifctoril etiology. CLP ffects not only crniofcil growth, but lso the dentition. Abnorml tooth size nd morphology re the most prevlent dentl bnormlities in CLP. 1 Dentl bnormlities, such s disturbnces in number, size, nd shpe, re more frequent in subjects with CLP thn in the generl popultion. 1 9 In CLP ptients, teeth in the region of n lveolr cleft, prticulrly the lterl incisors, re commonly Professor, Deprtment of Orthodontics, Fculty of Dentistry, University of Ankr, Ankr, Turkey. b Assistnt Professor, Orthodontist, Turgut Özl University Orl nd Dentl Helth Cre Center, Ankr, Turkey. c Professor, Deprtment of Peditric Dentistry, Fculty of Dentistry, University of Ankr, Ankr, Turkey. d Privte Prctice, Orthodontist, Trbzon, Turkey. Corresponding uthor: Dr Hlise Aydemir, Turgut Özl University, Orl nd Dentl Helth Cre Center, Alprsln Türkeş cddesi no. 57, Emek, Ankr, Turkey (e-mil: hsboltoglu@yhoo.com) Accepted: November 2013. Submitted: July 2013. Published Online: Jnury 14, 2014 G 2014 by The EH Angle Eduction nd Reserch Foundtion, Inc. mlformed, pegged, microformed, or congenitlly bsent. 1,10 12 Moreover, tooth size discrepncies cn be seen in both ffected nd nonffected sides 1,2,13,14 nd even in the lower dentition. 2 Vrious studies hve evluted tooth crown size in CLP ptients; however, there re mrked vritions in the published results. 5 The studies commonly evluted crown size discrepncies in the mesiodistl (MD) dimension only. 14 18 Mrkovic nd Djordjevic 19 found tht the cnines, premolrs, nd molrs were smller on the cleft side, but not to sttisticlly significnt degree. Rwshdeh nd Bkir 20 found tht the centrl nd lterl incisors were smller on the cleft side, but only the lterl incisor ws sttisticlly significntly smller. Werner nd Hrris 2 lso demonstrted significnt levels of symmetry between the cleft nd noncleft sides. With remrkble symmetry in tooth crown sizes, symmetric lignment of the teeth long smoothly curving line of occlusion with correct midline my not be possible. Few studies hve evluted tooth crown size in the MD, lbiolingul (LL), nd occlusogingivl (OG) dimensions, 8 nd symmetry in three dimensions hs not been evluted in unilterl (UCLP), bilterl (BCLP), nd Clss I groups. The current study DOI: 10-2319/072013-526.1 623
624 AKCAM, AYDEMIR, ÖZER, ÖZEL, TOYGAR-MEMIKOĞLU Tble 1. Sex nd Number Distribution nd Men Age of Ptients According to Groups Groups Femle Mle n Men ge (y) (6 SD ) ULCLP 18 16 34 17.5 6 4.1 URCLP 10 8 18 16.9 6 4.4 BCLP 11 9 20 18.3 6 4.6 Clss I 27 26 53 15.9 6 4.0 ULCLP indictes unilterl left cleft lip nd plte; URCLP, unilterl right cleft lip nd plte; BCLP, bilterl cleft lip nd plte; SD, stndrd devition. therefore imed to ssess nd compre tooth size symmetry on the right nd left sides of the mxill nd mndible in UCLP nd BCLP cses nd in Clss I group. MATERIALS AND METHODS This retrospective study ws done on dentl csts from the deprtment rchives ccording to the Ethics Committee of Ankr University. The pretretment orthodontic dentl csts of CLP ptients nd controls were selected from the rchives of Ankr University Fculty of Dentistry Deprtment of Orthodontics. Dentl csts from 125 ptients were divided into four groups: group 1, 20 BCLP ptients; group 2, 34 unilterl left (ULCLP) ptients; group 3, 18 unilterl right (URCLP) ptients; group 4, 53 Clss I subjects (Tble 1). Group 4 consisted of ptients with Clss I occlusion, idel overjet nd overbite, well-ligned dentl rches, nd norml dentoskeletl pttern with minor or no crowding. All subjects were in the permnent dentition stge. Only nonsyndromic subjects with good qulity dentl csts were included. Csts with missing, ectopic, pegged, microform, bsent, deformed, unerupted, or prtilly erupted teeth, or with teeth with lrge restortions or crowns were excluded. Mesurements were recorded with digitl cliper tht ws ccurte to within 0.01 mm (Mitutoyo Corp, Knzw, Jpn) (Figure 1). The MD, LL, nd OG (verticl) dimensions of the teeth were mesured ccording to the method of Hunter nd Priest. 21 The MD dimension ws mesured s the gretest distnce between the ntomic mesil nd distl contct points, the LL dimension ws mesured perpendiculr to the MD xis of the tooth, nd the OG dimension ws mesured on the lbiobuccl side to the gingivl border prllel to the xis of the tooth. Relibility The MD, LL, nd OG dimensions of teeth were mesured twice by the sme investigtor, nd the men vlues of the mesurements were recorded to Figure 1. Mesurements with digitl cliper. eliminte errors in the mesurements. The mesurements were repeted on 20 rndomly selected dentl csts. The first nd second mesurements were compred nd correltion coefficients (r 2 ) were obtined. Sttisticl Anlysis Descriptive sttistics (mens nd stndrd devitions) were clculted. Pired t-tests were performed to nlyze symmetry between the right nd left dentl rches in ech group. RESULTS The relibility of the mesurements ws high, with the correltion coefficients rnging between 0.9916 nd 0.9985. Asymmetry vlues were clculted s the men difference of the right nd left MD, LL, nd OG mesurements for the mxill nd mndible in ech group. Asymmetry vlues for the mxill nd mndible re shown in Tbles 2 nd 3, respectively. There ws no sttisticlly significnt difference in the mxillry MD dimension for ech group. In the ULCLP group, the mndibulr left first premolr ws significntly greter in the MD dimension nd significntly smller in the OG dimension. There ws no sttisticlly significnt difference in the mxillry rches in the CLP groups when the LL dimension ws evluted. However, in the mndible, the right first premolr ws bigger in the URCLP group. In the Clss I group, the mxillry right second premolr nd the mxillry nd mndibulr right lterl incisors nd cnines were significntly bigger in the LL dimension. When the OG dimensions were evluted, the mxillry left premolr, mndibulr right second premolr, nd mndibulr right second molr teeth were significntly bigger.
TOOTH SYMMETRY IN CLEFT PALATE 625 Tble 2. Pired T-Test Results Showing Right-Left (R-L) Side Asymmetry in Mxill ULCLP P URCLP P BCLP P Clss I P MD R1 - L1 0.18 6 0.480 20.10 6 0.589 0.13 6 0.356 20.03 6 0.204 R2 - L2 2.05 6 3.225 22.01 6 3.110 0.07 6 0.877 0.05 6 0.287 R3 - L3 0.01 6 0.446 0.05 6 0.345 20.15 6 0.299 0.01 6 0.258 R4 - L4 0.03 6 0.273 20.10 6 0.326 20.03 6 0.524 20.06 6 0.364 R5 - L5 0.16 6 0.379 0.13 6 0.346 0.07 6 0.456 20.08 6 0.372 R6 - L6 0.47 6 1.932 20.18 6 0.464 20.08 6 0.495 0.16 6 0.671 R7 - L7 0.24 6 0.447 0.09 6 0.465 0.17 6 0.447 20.10 6 0.925 LL R1 - L1 0.15 6 0.814 20.12 6 0.651 0.00 6 0.596 0.01 6 0.230 R2 - L2 2.54 6 3.875 22.08 6 3.080 0.05 6 0.113 0.16 6 0.375*** R3 - L3 0.50 6 0.382 0.15 6 0.200 20.26 6 1.351 0.14 6 0.371** R4 - L4 0.28 6 0.802 0.14 6 0.310 0.07 6 0.382 20.08 6 1.359 R5 - L5 0.21 6 0.564 20.21 6 1.344 0.04 6 0.483 0.10 6 0.343* R6 - L6 0.53 6 2.215 20.08 6 0.410 0.00 6 0.410 0.05 6 0.291 R7 - L7 20.09 6 0.506 20.31 6 0.572 20.03 6 0.480 0.33 6 1.525 OG R1 - L1 20.50 6 1.137* 0.81 6 1.600 20.80 6 0.872** 20.07 6 0.404 R2 - L2 0.11 6 4.022 20.09 6 3.170 0.48 6 0.431 20.14 6 0.542 R3 - L3 0.56 6 0.961 0.59 6 1.151 20.22 6 1.315 0.02 6 0.634 R4 - L4 0.72 6 1.104** 0.09 6 0.568 20.29 6 1.013 20.14 6 0.495* R5 - L5 0.20 6 0.938 0.30 6 0.595 20.33 6 1.176 0.05 6 0.442 R6 - L6 0.28 6 1.428 20.08 6 0.597 20.08 6 0.715 20.09 6 1.283 R7 - L7 0.46 6 0.870 0.17 6 1.100 20.14 6 0.630 20.01 6 0.821 * P,.05, ** P,.01, *** P,.001. MD indictes mesiodistl; LL, lbiolingul; OG, occlusogingivl; 1, centrl incisor; 2, lterl incisor; 3, cnine; 4, first premolr; 5, second premolr; 6, first molr; 7, second molr. In the ULCLP group, the mxillry left centrl incisor nd right first premolr nd the mndibulr right cnine, first premolr, nd first molr were significntly lrger in the OG dimension. In the BCLP group, the mxillry left centrl incisor ws lrger in the OG dimension. DISCUSSION A digitl cliper ws used for three-dimensionl mesurements in the current study. It hs been reported tht mesurements with digitl clipers on dentl csts showed the highest ccurcy nd reproducibility when compred to computerized models ssessed with the Ortho-CAD mesurement tool; digitl clipers were shown to be more suitble tool for scientific work. 22 Moreover, it ws reported tht mesurements involving Vernier clipers or needlepointed dividers on photocopies, photogrphs, nd hologrms of digitiztion of points from the dentl csts showed errors. 22 The study smple consisted of exclusively dolescent ptients with complete permnent dentition to eliminte the possibility of ttritionl size reduction or delyed eruption. Mxillry lterl incisors with bnorml morphology hve been reported in up to 94% of ptients with CLP on the cleft side. 1 Also, bnorml morphology of the centrl incisor on the cleft side hs been reported. 23 CLP ptients with missing, ectopic, pegged, microform, bsent, deformed, unerupted, or prtilly erupted teeth were excluded from the study to eliminte tooth size bnormlities nd evlute symmetries objectively with Clss I control group. Rwshdeh nd Bkir 20 found remrkble gender difference when symmetries in the upper nd lower rches were evluted in CLP ptients. According to their study, in men, lmost ll mndibulr teeth on the cleft side were lrger thn on the noncleft side. However, in women, most teeth on the cleft side were smller thn on the noncleft side. To void reduction in the number of subjects per group, we could not evlute the genders independently. However, the numbers of mle nd femle ptients in our study were lmost equl. We found tht the mxillry centrl nd lterl incisors nd first molrs were significntly lrger on the noncleft side in the MD dimension compred with the cleft side in unilterl CLP ptients. 5,7,24,25 In our study, we found no significnt difference in the MD dimension in the mxill. However, the lterl incisors were lrger in the MD nd LL dimensions on the noncleft side, lthough this difference ws not significnt. According to met-nlysis of Antonrkis et l., 24 in the mndibulr dentition, the centrl nd lterl incisors nd first nd second premolrs re lrger on the cleft side. Rwshdeh nd Bkir 20 lso found tht the mndibulr lterl incisors nd premolrs were lrger on the cleft side. In our study, in the ULCLP group, the mndibulr first premolrs were lrger in the MD dimension on the cleft side, wheres the mndibulr first premolrs were significntly lrger on the noncleft side in the LL dimension.
626 AKCAM, AYDEMIR, ÖZER, ÖZEL, TOYGAR-MEMIKOĞLU Tble 3. Pired T-Test Results Showing Right-Left (R-L) Side Asymmetry in Mndible ULCLP P URCLP P BCLP P Clss I P MD R1 - L1 20.04 6 0.188 0.01 6 0.182 20.04 6 0.157 20.07 6 0.448 R2 - L2 20.10 6 0.335 20.08 6 0.324 20.31 6 1.248 0.05 6 0.535 R3 - L3 0.12 6 0.689 0.11 6 0.391 20.12 6 0.310 0.06 6 0.578 R4 - L4 20.21 6 0.337** 0.19 6 0.420 0.03 6 0.370 20.01 6 0.318 R5 - L5 20.17 6 0.706 0.14 6 0.434 20.03 6 0.331 0.06 6 0.343 R6 - L6 0.02 6 0.437 0.08 6 0.167 0.07 6 0.371 0.04 6 0.636 R7 - L7 20.05 6 0.697 0.11 6 0.512 0.08 6 0.486 0.14 6 0.505 LL R1 - L1 0.06 6 0.301 0.06 6 0.129 20.01 6 0.177 0.02 6 0.212 R2 - L2 0.06 6 0.311 0.11 6 0.364 0.10 6 0.317 0.15 6 0.259*** R3 - L3 0.15 6 0.469 0.06 6 0.281 20.05 6 0.505 0.15 6 0.552* R4 - L4 0.15 6 0.498 0.03 6 0.355* 0.02 6 0.192 0.06 6 0.341 R5 - L5 0.29 6 0.613 0.20 6 0.213 0.05 6 0.197 0.00 6 0.453 R6 - L6 0.16 6 0.565 0.13 6 0.356 0.19 6 0.473 0.04 6 0.414 R7 - L7 0.28 6 0.927 0.69 6 1.540 0.12 6 0.468 0.15 6 0.536 OG R1 - L1 0.12 6 0.538 20.21 6 0.441 0.05 6 0.220 0.04 6 0.316 R2 - L2 0.15 6 0.643 0.13 6 0.832 20.15 6 0.429 0.01 6 0.401 R3 - L3 0.47 6 0.787** 20.02 6 1.044 20.15 6 0.678 0.10 6 0.712 R4 - L4 0.35 6 0.559** 20.07 6 0.884 20.05 6 0.547 20.04 6 0.595 R5 - L5 0.20 6 0.567 20.11 6 0.726 0.04 6 0.453 0.17 6 0.495** R6 - L6 0.27 6 0.643* 20.01 6 0.536 0.03 6 0.636 0.07 6 0.646 R7 - L7 0.26 6 0.483 0.10 6 1.078 20.11 6 0.546 0.27 6 0.657*** * P,.05, ** P,.01, *** P,.001. MD indictes mesiodistl; LL, lbiolingul; OG, occlusogingivl; 1, centrl incisor; 2, lterl incisor; 3, cnine; 4, first premolr; 5, second premolr; 6, first molr; 7, second molr. In the ULCLP group, the mxillry first premolr nd the mndibulr cnine, mndibulr first premolr, nd mndibulr first molr were bigger in the OG dimension on the noncleft side. However, we could not detect those symmetries in the URCLP group. Considering ll tooth types in the incisor nd molr field, mxillry teeth re not inherently more symmetric thn their mndibulr counterprts, even when the cleft is limited to the upper rch. We found no significnt symmetry except in the OG dimension of the mxillry centrl incisor in the BCLP group. However, in the Clss I group, we observed much more symmetry in the dentl rches (Tbles 2 nd 3). Sofer 26 nd Werner nd Hrris 2 reported high levels of tooth symmetry between the cleft nd noncleft sides in 77 ptients nd 63 noncleft controls. According to Sofer, 26 this generlized developmentl instbility is controlled geneticlly becuse ptients with positive fmily history showed some signs of greter symmetry. Since clefting is n isolting phenomenon occurring in erly fetl development, permnent teeth should not be ffected. However, environmentl fctors such s surgery in the cleft re cn ffect the teeth in the cleft region nd in the entire dentition becuse of the systemic effects of surgicl tretment nd feeding problems. 27 CONCLUSIONS N Dentl symmetries cn occur in nonsyndromic CLP ptients in the permnent dentition without missing, ectopic, pegged, microform, bsent, deformed, unerupted, or prtilly erupted teeth. N Three-dimensionl symmetries cn lso be found in Angle Clss I norml occlusion subjects. N There ws no sttisticlly significnt reltionship between clefting nd tooth symmetry in this comprison of cleft nd Clss I subjects. N Tooth size symmetry should be considered during tretment plnning in individuls with cleft. REFERENCES 1. Rnt R. A review of tooth formtion in children with cleft lip/ plte. Am J Orthod Dentofcil Orthop. 1986;90:11 18. 2. Werner SP, Hrris EF. Odontometrics of the permnent teeth in cleft lip nd plte: systemic size reduction nd mplified symmetry. Cleft Plte J. 1989;26:36 41. 3. Dixon DA. Defects of structure nd formtion of the teeth in persons with cleft plte nd the effect of reprtive surgery on the dentl tissues. Orl Surg Orl Med Orl Pthol. 1968; 25:435 446. 4. McCnce A, Roberts-Hrry D, Sherriff M, Mrs M, Houston WJ. Sri Lnkn cleft lip nd plte study model nlysis: clefts of the secondry plte. 1993;30:227 230. 5. Lewis BR, Stern MR, Willmot DR. Mxillry nterior tooth size nd rch dimensions in unilterl cleft lip nd plte. Cleft Plte Crniofc J. 2008;45:639 646. 6. Li MC, King NM, Wong HM. Abnormlities of the mxillry nterior teeth in Chinese children with cleft lip nd plte. Cleft Plte Crniofc J. 2009;46:58 64. 7. Rwshdeh MA, Abu Sirdneh EO. Crown morphologicl bnormlities in the permnent dentition of ptients with cleft lip nd plte. J Crniofc Surg. 2009;20: 465 470.
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