Tooth Maturation in Cleft Lip, Cleft Palate, or Both HaAnNELoRE T. Loevy, C.D., PH.D. Howarbp Apuss, D.D.S. The relation between chronologic age and the development of permanent teeth in patients with cleft lip, cleft palate, or both was investigated according to the method described by Demirjian et al (1973). The patients were divided into three groups: (1) those with bilateral cleft lip and palate (BCLP), (2) those with unilateral cleft lip and palate (UCLP), and (3) those with cleft palate only (CP). Panoramic radiographs of 107 Caucasian children (66 boys and 41 girls) aged 4 to 12 years were evaluated. The degree of maturation of each of the permanent teeth on the left side of the mandible was determined, and a dental maturation score was computed for each child. The scores were compared with those obtained in a previous study of dental maturation in Caucasian children without cleft from the Chicago area (Loevy, 1983). Evaluation of the data demonstrated that there was no significant difference in dental maturity between girls with cleft lip, cleft palate, or both and with the sample of those free from cleft. There was a significant difference in dental maturity in boys when all cleft groups were evaluated together. There was no significant difference from the normal sample in boys with bilateral cleft lip and cleft palate or with cleft palate alone, but there was a highly significant difference from the normal sample in the group of boys with unilateral cleft lip and palate. KEY WORDS: dental maturation, cleft lip, cleft palate, growth and development, tooth development. The relationship between dental, skeletal, and chronological age is not well defined. Close correlations have been found by some investigators (Anderson et al, 1975), whereas others have reported either moderate or no correlation (Sutow et al, 1954; Demirjian et al, 1985). The lack of clear-cut correlations becomes even more complex when attention is focused on children with cleft lip and palate. In addition, irregularities of tooth position in the region of clefts and the higher incidence of enamel hypoplasia as well as morphologic irregularities have been described in patients with cleft. (Bohn, 1963; Olin, 1964; Kraus et al, The authors are affiliated with the Department of Pediatric Dentistry, the Department of Pediatrics, and the Center for Craniofacial Anomalies, Colleges of Dentistry and Medicine, University of Illinois at Chicago, IL. This study was supported in part by grant DE 02872 from the National Institute of Dental Research. The results herein are based on a paper presented at the 65th annual session of the International Association for Dental Research, March 12, 1987, Chicago, IL. 1966). Bohn (1963) also reported reduced tooth size in these patients. Few studies have examined the pattern of tooth maturation in children with cleft. Tooth formation in patients with cleft lip with or without cleft palate has been described as conspicuously lagging behind that of normal children (Ranta, 1972). This retardation in tooth formation has been postulated to be caused by genetic factors (Jordon et al, 1966) or by the indirect effects of the cleft on postnatal development (Ranta, 1971). Asymmetry in eruption patterns between the cleft side and the noncleft side has been observed in patients with unilateral cleft lip and palate (Ranta, 1971). Prahl-Andersen (1976) found that in a group of 91 children aged 5 to 14 years there was a tendency for children affected with cleft to show delayed dental development until the age of 9 years. After that age, there was no further evidence of delayed dental development. Boys with cleft, older than 9 years, did not differ significantly from normal children. For girls with cleft, a similar tendency toward delay dur- 343
_ 344 Cleft Palate Journal, October 1988, Vol. 25 No. 4 ing earlier years was noted but there was no statistically significant difference from the sample of those without cleft. These findings contradict Ranta (1972), who found delay in dental development in older children. In a later study in which 189 patients with cleft were evaluated, Prahl-Andersen (1979) concluded that there was no difference in dental maturation in females with or without cleft palate. However, there was a retardation in dental development in: boys with cleft when compared with the sample of those without cleft. With the preceding in mind, this study was designed to compare the dental maturation schedule of a group of children with cleft lip, cleft palate, or both with population free from cleft. MATERIAL AND METHOD The patients with cleft lip, cleft palate, or both selected for this study had been evaluated at the Center for Craniofacial Anomalies at the University of Illinois at Chicago. The findings in these patients were compared with the data on maturation patterns reported for Chicago area children without cleft (Loevy, 1983). Panoramic radiographs were used to assess dental maturation. The first good-quality panoramic film obtained was analyzed; only one radiograph was used for each child. The original sample consisted of 83 boys and 50 girls with cleft. However, our previous study (Loevy, 1983) demonstrated that dental maturation for Chicago area blacks and Hispanics differed significantly from that of Caucasians. Since our sample of blacks and Hispanics with cleft was not large enough to be compared independently with our black and Hispanic controls, the present study was restricted to Caucasian children. The final sample consisted of 66 boys and 43 girls with cleft. Patients were classified according to type of cleft; boys and girls were analyzed separately. The age of the patients ranged from 4 years 6 months to 12 years, with an average age of 8 years 1 month. A control series of normal Caucasian children who were patients at the University of IIlinois was available from an earlier study (Loevy, 1983). This sample was used because of the similarity in age and socioeconomic status of the two populations. Dental maturation was scored according to the method described by Demirjian et al (1973). According to this method, the stages of development of each tooth are defined according to maturity. A total of eight stages (A to H) for each tooth was described, taking calcification and root development into consideration. Stage A in both uniradicular and multiradicular teeth indicates the beginning of calcification in the form of a small inverted cone at the most occlusal part of the crypt. Stage H is defined as the point in time at which the apex of the tooth is completed and the periodontal membrane is uniformly wide around the root and its apex. After each tooth has been evaluated and given a letter score depending on its degree of maturation, the letters are translated into numerical scores derived from standard tables that take sex into consideration. The numerical score for the quadrant is the sum of the scores of the individual teeth that were evaluated. This numerical score is converted into a dental age score using the appropriate table of standards, girls and boys being evaluatedon separate standards. For uniformity, all the teeth of the left lower quadrant, with exception of the third molars, are the ones used for this evaluation. According to the method of Demirjian et al (1973), the scores of each patient in the study are plotted on a graph, with the chronologic age as the abscissa and the quadrant score as the ordinate. Separate graphs have been standardized for boys and girls. These graphs demonstrate percentiles of dental maturation. Like growth charts, 50% of the children at each age have tooth maturation scores below the 50th percentile line, 10% below the 10th percentile line, and so on. The same definition applies to the upper percentiles. The findings were analyzed using the chi square (x2) test for goodness of fit (Conover, 1971). FNDINGS Table 1 shows the sample size and distribution according to age, sex, and cleft type at time of radiographic evaluation. Tables 2 through 5 present the findings obtained in our sample. In each table, the percentile intervals in the first column are derived from Demirjian's graphs. The second and fifth columns show the distribution of our control sample of Chicago area Caucasian children. The third and sixth columns give the observed numbers of children with cleft in each percentile interval. The fourth and seventh columns indicate the number that would be expected in each percentile interval if the distribution of the patients with cleft were exactly the same as that of the controls without cleft. These values are obtained by considering the total number of control patients in a particular group and computing the proportion of control patients that fall
Loevy and Aduss, TootH MATURATION 345 TABLE 1 Sample Analyzed: Summary of Age Range and Number of Female and Male Subjects in Each of the Cleft Categories Females Males Age (Yrs) Bilat. Unilat. Cl. Palate Bilat. - Unilat. Cl. Palate 4-6 1 2. 3 6-8 6 6 5 5 7 7 8-10 2 10 7 13 12 4 10-12 1 4 1 5 6 2 TOTAL 9 20 14 25 28 13 Abbreviations: Bilat. = Bilateral cleft lip and palate; Unilat. = unilateral cleft lip and palate (either right or left); Cl. palate = cleft palate only. in a given percentile. The expected value is the same proportion of the total number of cleft patients in the particular group. As can be seen from Tables 2 through 5, in none of the female groups was there a significant difference between the sample with cleft and the controls without cleft. However, when the data from males were analyzed, there were some significant differences. When we consider all types of clefts together (see Table 2), there is a significant difference in distribution between those with cleft and the controls, since the greater proportion of the sample without cleft is in the 50th to 90th percentile. If we consider only the bilateral clefts, there is no statistically significant difference from the distribution of the male controls. However, for males with unilateral cleft lip and palate, there is a highly significant difference from the male controls; a larger proportion of the group with cleft is in the 50 to 90 percentile interval. It would appear that the findings in males with complete unilateral cleft lip and palate account for the significant difference between control males and all males with cleft taken together. The group With cleft palate alone did not differ significantly from the control sample. DIscUssION Considerable differences in relation to time and sequence of eruption of permanent teeth have been reported between populations. Although some of these differences may reflect inappropriate methodology or choice of sample, other studies clearly indicate differences because of systemic or local factors or both. Among the systemic conditions, cleft lip and palate should be considered, since many factors associated with these conditions may alter the state of health of the child. Since its establishment by Crampton in 1908, the concept of physiologic age has been considered important for the evaluation of a child's development and for clinical diagnosis and treatment planning. In assessing a child's physiologic age, chronologic age is frequently misleading because of the extreme variability among children. Tooth emergence has long been used for evaluation of age, but it too can be inaccurate. TABLE 2 All Types of Cleft: Comparison of Sample and Control Groups in Males and Females <3% 4 1 1.74 4 0 2.64 3-10% 8 3 3.47 11 5 7.26 10-50% 29 10 12.60 31 17 20.47 50-90% 28 16 12.16 28 30 18.49 90-97% 19 11 8.25 15 8 9.90 >97% 11 2 4.78 14 8 9.24 N 99 43 43 103 68 68 * x" = 4.65; p > 0.25 (NS). t x? = 11.64; p < 0.05 (Sig). The control samples are from our previous study (Loevy, 1983). The expected values are those that would be found if the distribution of patients with cleft were the same as that of the controls. Abbreviations: NS = not significant; Sig = significant.
346 Cleft Palate Journal, October 1988, Vol. 25 No. 4 TABLE 3 Bilateral Cleft Lip With Cleft Palate: Comparison of Sample and Control in Males and Females <3% 4 0 0.36 4 0 0.97 3-10% 8 1 0.72 11 3 2.67 10-50% 29 2 2.63 31 8 7.62 50-90% 28 3 2.54 28 7 6.80 90-97% 19 3 1.75 15 4 3.64 >97% 11 0 1.00 14 3 3.40 N 99 9 9 103 25 25 * x2 = 2.64; p > 0.25 (NS). t y? = 1.13; p > 0.25 (NS). Abbreviation: NS = not significant. Tooth emergence may be influenced by environmental factors such as infection and loss of primary teeth, crowding, and trauma. Premature shedding of primary teeth apparently also plays a role in the eruption of the succedaneous teeth (Ohta, 1967). There are also variations in obtaining and evaluating of data, since some investigators base their data on tooth emergence into the oral cavity whereas others use radiographic examination to study tooth development and eruption. The time and order of eruption of teeth differ somewhat among populations and geographic areas. Variations may also be due to socioeconomic conditions (LaVelle, 1976). Studies have also shown a delay in eruption in patients with malformations and malocclusion (Lysell, 1969). Dental abnormalities in patients with cleft have been studied by several investigators. Bohn (1983) found 38.4% of his sample of 198 patients exhibited hypodontia. In another study (Kraus et al, 1966) of 39 dental casts of patients with cleft lip, cleft palate, or both, morphologic irregularities of the crown structure were found in a large proportion of cases. Mandibular teeth were affected as frequently as were maxillary teeth, and the malformations were not restricted to the cleft region. Assessment of tooth size in 55 patients demonstrated that teeth in subjects with cleft lip and palate were appreciably smaller then those in controls (Foster and LaVelle, 1971). However, very few studies have evaluated dental maturation in patients with cleft. Bailit et al (1968) studied 39 children (22 boys, 17 girls) aged 5 to 15 years using an age- and sexspecific scoring system. They found tooth formation in patients with cleft palate to be significantly delayed compared with that in controls, but no details of their methodology were presented. Unfortunately, no follow-up for this TABLE 4 Unilateral Cleft Lip With Cleft Palate: Comparison of Sample and Control in Males and Females <3% 4 0 0.81 4 0 1.09 3-10% 8 0 1.62 11 0 2.99 10-50% 29 4 5.86 31 6 8.43 50-90% 28 7 5.66 28 18 7.61 90-97% 19 7 3.84 15 1 4.08 >97% 11 2 2.22 14 3 3.81 N 99 20 20 103 28 28 * y 5.96, p > 0.1 (NS). { y2 21.45; p < 0.001 (H Sig). Abbreviations: NS = not significant; Sig = Significant.
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