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.
Cone-beam computed tomography images of 51 patients were divided into 2 groups (group 1, 21 patients affected by BCLP; mean age; 14.62 ± 2.89 years; and group 2, 30 patients as the noncleft control group; mean age, 14.22 ± 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.
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).
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.
Dehiscences and fenestrations were assessed in the anterior teeth of BCLP patients.
CBCT images were used in this retrospective study.
Dehiscences were higher in anterior teeth of the BCLP group compared with controls.
Fenestrations were higher in the maxillary central incisors of the BCLP group compared with controls.
Cleft 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.
Patients affected by CLP have complaints of mouth breathing, snoring, and hypopnea during sleep, and also have feeding, speaking, hearing, and esthetic problems. 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. In addition, these patients were reported to be at risk for the development of periodontitis and mucogingival problems. Salvi et al reported a high incidence of plaque and bleeding on probing and a high level of periodontal attachment loss in these patients. Ercan et al 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.
Although some studies investigated dehiscence and fenestration in patients with different sagittal and vertical malocclusions, it was almost neglected for the patients affected by CLP. Buyuk et al 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, 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, 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 ± 2.89 years) affected by BCLP and group 2 consisted of 30 patients (8 girls, 22 boys; mean age, 14.22 ± 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 ).
|Inclusion criteria||Exclusion criteria|
|BCLP group||Complete BCLP
Surgical closure of the lip and palate before the age of 3 years
Good quality images
|Previous orthodontic (fixed or removable appliances) and prosthodontic treatment
History of trauma
Previous orthognathic surgery
|Control group||Normal healthy subjects
Good quality images
Previous orthodontic and prosthodontic treatment
History of trauma
Previous orthognathic surgery
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 ). 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°) and SN-MP (high-angle group, >38°; low-angle group, <26°; normal-angle group, 26°–38°) parameters in both study and control groups with 3D cephalometry.
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 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.
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.
Intraexaminer and interexaminer reliability scores were 100% for the assessment of both dehiscence and fenestration. The Houston test confirmed the reliability of those measurements showing the growth patterns of the patients (r > 0.952).
The comparisons of the chronologic ages (14.62 ± 2.89 and 14.22 ± 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 ( 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 ).
|Mean age (y)||Female/Male||Sagittal growth pattern||Vertical growth pattern|
|Class I/Class II/Class III||H-A/L-A/N-A|
|BCLP group (n = 21)||14.62 ± 2.89||3/18||2/9/10||5/9/7|
|Control group (n = 30)||14.22 ± 1.05||8/22||26/4/0||1/2/27|
|P||0.555 ∗||0.318 †|
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.
|Tooth type||BCLP group||Control group||P ∗|
|Dehiscence presence||Dehiscence presence|
|Yes (%)||No (%)||Yes (%)||No (%)|
|Maxillary central incisor||32/42 (76.19)||10/42 (23.81)||8/60 (13.33)||52/60 (66.67)||0.000|
|Maxillary lateral incisor||3/6 (50.0)||3/6 (50.0)||4/60 (6.67)||56/60 (93.33)||0.000|
|Maxillary canine||20/42 (47.62)||22/42 (52.18)||2/60 (3.34)||58/60 (66.66)||0.000|
|Total||55/90 (61.11)||35/90 (38.89)||14/180 (7.78)||166/180 (92.22)||0.000|
|Mandibular central incisor||28/42 (66.67)||14/42 (33.33)||23/60 (38.33)||37/60 (51.67)||0.004|
|Mandibular lateral incisor||18/42 (42.86)||24/42 (57.14)||6/60 (10.0)||54/60 (90.0)||0.000|
|Mandibular canine||15/42 (35.71)||27/42 (64.29)||1/60 (1.67)||59/60 (100.0)||0.000|
|Total||61/126 (48.41)||65/126 (51.59)||30/180 (16.67)||150/180 (83.33)||0.000|
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.