Abstract
Aim: To evaluate the dental development of Brazilian children and adolescents with cleft lip and palate. Methods: The sample consisted of 107 panoramic radiographs of children and adolescents with cleft lip and/or palate (cleft group) and 107 panoramic radiographs of children and adolescents without cleft lip and/or palate (control group), with chronological ages ranging from 6 to 15 years, matched in gender and chronological age within 60 days. Radiographs were digitized and masked and dental age was assessed using the method described by Demirjian et al. (1973). Three trained examiners conducted the assessments. Each examiner evaluated the radiographs three times. Data were statistically analyzed using non-parametric tests and univariate linear regression (p<0.05). Results: The dental age was overestimated in relation to the chronological age in both groups (p<0.0001). Compared to the control group, there was a delay in the dental age in the cleft group of 0.17 years (2.1 months). However, no statistically significant difference in the dental age between the cleft and the control group was found even when considering the different cleft types (p=0.152). Conclusions: There was no statistically significant difference in the dental age between the cleft and the control groups. The evaluation of dental development in individuals with cleft lip and palate should be approached in the same way as in individuals without clefts, with a focus on the individualization of diagnosis and treatment planning.
cleft lip; cleft palate; dentition, permanent
Introduction
Cleft lip and palate is the most common congenital malformation of the face. This morphologic deformity affects 1 in every 1000 births11. World Health Organization. Global strategies to reduce the health-care burden of craniofacial anomalies. Geneva: The Organization; 2002. and impacts on quality of life. Specifically, cleft lip and palate compromise dentomaxillofacial aesthetics and function culminating in psychosocial disorders11. World Health Organization. Global strategies to reduce the health-care burden of craniofacial anomalies. Geneva: The Organization; 2002.
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22. Freitas JAS, Garib DG, Oliveira TM, Lauris RCMC, Almeida ALPF, Neves LT, et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC/USP) - Part 2: pediatric dentistry and orthodontics. J Appl Oral Sci. 2012; 20: 268-81.. In this context, treatment is challenging and requires a continuous multidisciplinary approach22. Freitas JAS, Garib DG, Oliveira TM, Lauris RCMC, Almeida ALPF, Neves LT, et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC/USP) - Part 2: pediatric dentistry and orthodontics. J Appl Oral Sci. 2012; 20: 268-81.
3. David DJ, Smith I, Nugent M, Richards C, Anderson PJ. From birth to maturity: a group of patients who have completed their protocol management. Part III. Bilateral cleft lip-cleft palate. Plast Reconstr Surg. 2011; 128: 475-84.
4. Toscano D, Baciliero U, Gracco A, Siciliani G. Long-term stability of alveolar bone grafts in cleft palate patients. Am J Orthod Dentofacial Orthop. 2012; 142: 289-99.
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55. Farronato G, Kairyte L, Giannini L, Galbiati G, Maspero C. How various surgical protocols of the unilateral cleft lip and palate influence the facial growth and possible orthodontic problems? Which is the best timing of lip, palate and alveolus repair? Literature review. Stomatologija. 2014; 16: 53-60..
Mostly, orthodontic treatment is essential for rehabilitation of aesthetics and function of cleft lip and palate children. However, this treatment is often prolonged due to the complexity of the situation. In order to simplify the treatment approach, accurately knowing the time for orthodontic intervention, assessment of dental maturity is of great clinical relevance22. Freitas JAS, Garib DG, Oliveira TM, Lauris RCMC, Almeida ALPF, Neves LT, et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC/USP) - Part 2: pediatric dentistry and orthodontics. J Appl Oral Sci. 2012; 20: 268-81.. Additionally, information concerning the ideal time for alveolar bone grafting is obtained in forehand, enabling a better surgical planning44. Toscano D, Baciliero U, Gracco A, Siciliani G. Long-term stability of alveolar bone grafts in cleft palate patients. Am J Orthod Dentofacial Orthop. 2012; 142: 289-99. , 66. Osawa T, Omura S, Fukuyama E, Matsui Y, Torikai K, Fujita K. Factors influencing secondary alveolar bone grafting in cleft lip and palate patients: prospective analysis using CT image analyzer. Cleft Palate Craniofac J. 2007; 44: 286-91..
In accordance to the clinical relevance of assessing dental maturity in cleft lip and palate patients, several authors reported outcomes of investigations in specific populations, such as North Americans77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
8. Loevy HT, Aduss H. Tooth maturation in cleft lip, cleft palate, or both. Cleft Palate J. 1988; 25: 343-7.
9. Pham AND, Seow WK, Shusterman S. Developmental dental changes in isolated cleft lip and palate. Pediatr Dent. 1997; 19: 109-13.
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1010. Borodkin AF, Feigal RJ, Beiraghi S, Moller KT, Hodges JS. Permanent tooth development in children with cleft lip and palate. Pediatr Dent. 2008; 30: 408-13. and Dutch1111. Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
12. Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
-
1313. Huyskens RWF, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006; 43: 612-5.. Howerer, the accessment of dental maturity in cleft lip and palate patients was not performed in a Brazilian population up to the present date. Based on that, the present study aims to compare the dental development of Brazilian cleft lip and palate patients with a control group paired by chronological age and gender, contributing for further clinical diagnosis and surgical planning.
Materials and methods
Sample Selection
The study was approved by the Ethics Committee of the Division of Health Sciences, Federal University of Paraná (Curitiba, PR, Brazil). The sample consisted of 107 panoramic radiographs of children and adolescents with cleft lip and/or palate (cleft group) and 107 panoramic radiographs of children and adolescents without cleft lip and/or palate (control group), with chronological ages ranging from 6 to 15 years, matched in gender and chronological age within 60 days.
The cleft group sample was obtained from the analysis of medical records and panoramic radiographs of 160 patients with cleft lip and/or palate in a specialized treatment center. Patients presenting incomplete medical records, syndromes, systemic diseases, dental agenesis or missing permanent teeth in the mandibular left hemiarch, low-quality panoramic radiographs, and age below 6 years old or over 15 years old at the radiographic exam date were excluded from the study.
The control group consisted of the data of medical records and panoramic radiographs of children and adolescents without cleft lip and/or palate. The exclusion criteria applied for the case group were repeated for control group sampling.
No racial or ethnic data were recorded for both case and control groups. The subjects included in the sample are mainly from the state of Paraná, located in Southern Brazil. The population of this region is mainly of European descent, but also has individuals of African and indigenous origin. Therefore, the sample is characterized by large racial and ethnic heterogeneity, like most of the Brazilian population.
Scanning and Blinding
In order to avoid potential bias during the analysis, radiographs were digitized masking the identification information, including gender and date of birth. The radiographs were digitized using a scanner (Scanjet G4050) and the software Digitalização HP (Hewlett-Packard Company, Palo Alto, CA, USA). The levels of brightness and contrast indicated by the software were respected. The used standard resolution was 150 PPI (pixels per inch), on a 100% scale. Images were saved in TIFF (Tagged Image File Format), which allows generation of high quality scanned images. To identify the digitized image files, a legend of random numbers was created. Only after completing all the analyses, the examiners had access to the original identification information. In addition, the region corresponding to the maxilla was previously cut, preventing visualization of cleft areas.
Evaluation of Dental Age
Dental age was determined using the method described by Demirjian et al.14 14. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol. 1973; 45: 211-27.(1973). This method is based on the evaluation of the seven left mandibular permanent teeth, excluding the third molar. The formation of each tooth is divided into eight stages, from A to H, from appearance of the first points of calcification until apex closure. Each stage of tooth development corresponds to a score, which is different for males and females. The sum of the scores of the seven evaluated teeth on a panoramic radiograph corresponds to the maturity score, represented on a scale of 0 to 100. The score of maturity, in turn, must be converted into the dental age, using two tables - one for males and other for females.
Radiographs were evaluated in a 20-inch computer monitor in low light environment. Three trained examiners evaluated the radiographs: an oral radiologist, an orthodontist and a dental practitioner. After studying the method and training with 30 radiographs, wich were not included in the sample, each examiner evaluated the radiographs three times with a three-day interval between assessments. An average of the maturity scores obtained in the three assessments of each examiner was calculated and then a final average from the three examiners was established. The final average of maturity scores of the three examiners was converted into the dental age of each patient.
Statistical Methods
Data were analyzed using the Statistical Package for the Social Sciences (version 15.0, SPSS Inc., Chicago, IL, USA). The outcome variable considered for statistical analysis was the dental age. As there was no normal distribution of this variable (Kolgomorov-Smirnov test, p<0.001), non-parametric tests for bivariate analyses were used (chi-square and Mann-Whitney U). To compare the dental age between the cleft and control groups, Wilcoxon test was used due the dependence between observations. This test was also used for the comparison between dental age and chronological age. The relationship between dental age and chronological age in both groups was also analysed by linear regression analysis. A significance level of 5% was adopted.
In order to test accuracy and reability of the method, the intraclass correlation coefficient was used to assess intra- and inter-examiner agreement. The test was applied to the maturity scores obtained in the assessments of the first 30 radiographs. For intra-examiner analysis, the scores of maturity achieved in each of the three assessments of each examiner were compared. For inter-examiner analysis, the averages of the scores of maturity of the three examiners were compared.
Results
Error of Method
Intra-examiner analysis showed intraclass correlation coefficients of 0.999, 0.998 and 0.994. The result of the inter-examiner analysis was 0.995. These results indicate very good intra- and inter-examiner agreement.
Sample Characteristics
Of the 107 pairs of children and adolescents evaluated in the study, 68 (63.6%) were males and 39 (36.4%) were females. The average chronological age was 10.3 years for boys and 9.8 years for girls. Among the individuals in the case group, 72 (68.2%) had cleft lip and palate (CLP), 27 (25.2%) had cleft lip with or without cleft alveolus (CL±A) and 2 (1.9%) had cleft palate (CP). In 6 patients (4.7%), there was an association between CL±A and CP (CL±A + CP). For the CLP and the CL±A, unilateral clefts were more frequent (77%) and the left side was more often affected (63.6%).
The distribution of cleft types by gender is shown in Table 1. CLP was the most frequent type of cleft followed by CL±A for both genders. The relative frequency of CLP was higher for boys (72.1%) than for girls (61.5%). Oppositely, the relative frequency of CL±A was higher for girls (28.2%) than for boys (23.5%). However, considering the CLP and CL±A groups, no statistically significant difference was found between cleft type and gender (p=0.464). In the CP and CL±A + CP group, the small number of individuals prevented the application of statistical tests to the variables gender and cleft type.
Dental Development
Table 2 shows the descriptive statistics for the variables chronological age and dental age in cleft and control groups. The average dental age in both the cleft and the control groups was higher than the average chronological age. Dental age, therefore, was advanced in relation to chronological age in both groups, which was statistically significant for both groups (p<0.0001). Specifically, the advance corresponded to 0.81 years (9.7 months) for the cleft group and 0.98 years (11.8 months) for the control group. This result shows a delay of 0.17 years (2.1 months) in dental age in the cleft group compared to the control group; however, this difference was not statistically significant (p=0.152).
The dental ages of the cleft and control groups were also compared considering the different genders, cleft types and chronological age groups (6-9; 9.1 to 12; 12.1 to 15 years). Once again, no statistically significant difference (p>0.05) was found as shown in Table 3. Table 4 shows the comparison of dental development between different genders and groups (cleft and control), considering the mean of differences between the dental and chronological age. As it can be seen, there was no statistically significant difference (p>0.05).
A strong and positive correlation between dental age and chronological age in the control and cleft groups was observed (r=0.9348, p<0.001, r=0.9198, p<0.001, respectively). Linear regression was used to show how much of the variation in dental age was explained by chronological age. Estimated regression showed that chronological age alone explained 87.38% of the dental age variation in the control group (Figure 1) and 84.61% in the cleft group (Figure 2).
Diagram showing the relationship between chronological age in years and dental age in the control group. Estimated regression equation, correlation coefficient (r), coefficient of determination (r(2)) and significance level (p) are also shown.
Diagram showing the relationship between chronological age in years and dental age in the cleft group. Estimated regression equation, correlation coefficient (r), coefficient of determination (r(2)) and significance level (P) are also shown.
Discussion
In the medical literature, several authors reported population-specific results for the assessment of dental maturity in cleft lip and palate patients by comparison between cleft and control groups. In some of them, however, the cleft and the control groups were not paired by gender and/or chronological age77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
-
88. Loevy HT, Aduss H. Tooth maturation in cleft lip, cleft palate, or both. Cleft Palate J. 1988; 25: 343-7.
,
1111. Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
12. Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
-
1313. Huyskens RWF, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006; 43: 612-5.. In the present study, a control group was designed pairing patients by gender and chronological age, making the present outcomes more suitable to a population-specific survey.
Moreover, in the present investigation a larger sample is observed if compared to previous reports77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
,
99. Pham AND, Seow WK, Shusterman S. Developmental dental changes in isolated cleft lip and palate. Pediatr Dent. 1997; 19: 109-13.
10. Borodkin AF, Feigal RJ, Beiraghi S, Moller KT, Hodges JS. Permanent tooth development in children with cleft lip and palate. Pediatr Dent. 2008; 30: 408-13.
11. Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
12. Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
-
1313. Huyskens RWF, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006; 43: 612-5.
,
1515. Harris EF, Hullings JG. Delayed dental development in children with isolated cleft lip and palate. Arch Oral Biol. 1990; 35: 469-73.
16. Eerens K, Vlietinck R, Heidbüchel K, Olmen AV, Derom C, Willems G, et al. Hypodontia and tooth formation in groups of children with cleft, siblings without cleft, and nonrelated controls. Cleft Palate Craniofac J. 2001; 38: 374-8.
17. Mitsea AG, Spyropoulos MN. Premolar development in Greek children with cleft lip and palate. Quintessence Int. 2001; 32: 639-46.
18. Tan ELY, Yow M, Kuek MC, Wong HC. Dental maturation of unilateral cleft lip and palate. Ann Maxillofac Surg. 2012; 2: 158-62.
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1919. Bindayel NA, AlSultan MA, ElHayek SO. Timing of dental development in Saudi cleft lip and palate patients. Saudi Med J. 2014; 35: 304-8. highlighting a strong reliability. In addition, contrarily to previous studies77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
8. Loevy HT, Aduss H. Tooth maturation in cleft lip, cleft palate, or both. Cleft Palate J. 1988; 25: 343-7.
-
99. Pham AND, Seow WK, Shusterman S. Developmental dental changes in isolated cleft lip and palate. Pediatr Dent. 1997; 19: 109-13.
,
1111. Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
12. Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
-
1313. Huyskens RWF, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006; 43: 612-5.
,
1515. Harris EF, Hullings JG. Delayed dental development in children with isolated cleft lip and palate. Arch Oral Biol. 1990; 35: 469-73.
,
1717. Mitsea AG, Spyropoulos MN. Premolar development in Greek children with cleft lip and palate. Quintessence Int. 2001; 32: 639-46.
18. Tan ELY, Yow M, Kuek MC, Wong HC. Dental maturation of unilateral cleft lip and palate. Ann Maxillofac Surg. 2012; 2: 158-62.
19. Bindayel NA, AlSultan MA, ElHayek SO. Timing of dental development in Saudi cleft lip and palate patients. Saudi Med J. 2014; 35: 304-8.
-
2020. Lai MC, King NM, Wong HM. Dental development of Chinese children with cleft lip and palate. Cleft Palate Craniofac J. 2008; 45: 289-96. a blinding methodology was applied to avoid potential bias during the image analysis. The blinding methodology plays an important part in the study reliability, since the method of Demirjian et al.14 14. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol. 1973; 45: 211-27.(1973) presents a certain degree of subjectivity. Some teeth are in intermediate stages of development (e.g. between stages D and E) potentially hampering the process of age estimation. If the examiner knows that the radiography belongs to an individual with cleft, he may tend to choose a premature stage, since the literature reports that the dental development in these individuals is delayed. Therefore the importance of blinding is justified. Furthermore, in relation to the image analysis, it is relevant to note that three calibrated examiners performed the assessment of dental maturity. Only two previous studies1212. Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
,
17 17. Mitsea AG, Spyropoulos MN. Premolar development in Greek children with cleft lip and palate. Quintessence Int. 2001; 32: 639-46.report these standards to achieve greater reliability.
The method of Demirjian et al.14 14. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol. 1973; 45: 211-27.(1973) was applied in the present sample, revealing a slight developmental delay of the dental age in the cleft group, therefore not statistically significant. Similarly, Eerens et al.16 16. Eerens K, Vlietinck R, Heidbüchel K, Olmen AV, Derom C, Willems G, et al. Hypodontia and tooth formation in groups of children with cleft, siblings without cleft, and nonrelated controls. Cleft Palate Craniofac J. 2001; 38: 374-8.(2001) reported a slight delay in the dental development of Belgian children. Despite the concordance, both studies contradict most of the previous investigations77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
,
99. Pham AND, Seow WK, Shusterman S. Developmental dental changes in isolated cleft lip and palate. Pediatr Dent. 1997; 19: 109-13.
10. Borodkin AF, Feigal RJ, Beiraghi S, Moller KT, Hodges JS. Permanent tooth development in children with cleft lip and palate. Pediatr Dent. 2008; 30: 408-13.
11. Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
12. Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
-
1313. Huyskens RWF, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006; 43: 612-5.
,
1515. Harris EF, Hullings JG. Delayed dental development in children with isolated cleft lip and palate. Arch Oral Biol. 1990; 35: 469-73.
,
1717. Mitsea AG, Spyropoulos MN. Premolar development in Greek children with cleft lip and palate. Quintessence Int. 2001; 32: 639-46.
18. Tan ELY, Yow M, Kuek MC, Wong HC. Dental maturation of unilateral cleft lip and palate. Ann Maxillofac Surg. 2012; 2: 158-62.
19. Bindayel NA, AlSultan MA, ElHayek SO. Timing of dental development in Saudi cleft lip and palate patients. Saudi Med J. 2014; 35: 304-8.
-
2020. Lai MC, King NM, Wong HM. Dental development of Chinese children with cleft lip and palate. Cleft Palate Craniofac J. 2008; 45: 289-96., which reported statistically significant delays in the dental development of individuals with cleft lip and palate. Moreover, some studies lack information concerning the performed methodology77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
,
1515. Harris EF, Hullings JG. Delayed dental development in children with isolated cleft lip and palate. Arch Oral Biol. 1990; 35: 469-73., hampering adequate interpretations. Yet other authors performed different methods for dental age assessment, not allowing for accurate comparisons1111. Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
,
1717. Mitsea AG, Spyropoulos MN. Premolar development in Greek children with cleft lip and palate. Quintessence Int. 2001; 32: 639-46.. In the study of Bindayel et al.19 19. Bindayel NA, AlSultan MA, ElHayek SO. Timing of dental development in Saudi cleft lip and palate patients. Saudi Med J. 2014; 35: 304-8.(2014) no control group was used, which may compromise the reliability of the results.
Thus, the differences observed in the current study when compared with other studies that evaluated the dental development of individuals with cleft lip and palate may be explained by the applied methodological design, considering aspects such as sample size, pairing of the sample, blinding, number of examiners and number of radiograph evaluations per examiner. Moreover, ethnic and racial differences among the surveyed populations may have contributed to these differences.
Furthermore, in the present study individuals with agenesis in mandibular left hemiarch were excluded. The etiologic factors of delayed dental development of individuals with clefts seem to be the same factors responsible for the occurrence of dental anomalies in these individuals, as well as for the manifestation of the cleft itself77. Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664. , 1616. Eerens K, Vlietinck R, Heidbüchel K, Olmen AV, Derom C, Willems G, et al. Hypodontia and tooth formation in groups of children with cleft, siblings without cleft, and nonrelated controls. Cleft Palate Craniofac J. 2001; 38: 374-8. , 2121. Ranta R. A review of tooth formation in cleft lip/palate. Am J Orthod Dentofacial Orthop. 1986; 90: 11-8.. Moreover, the delay tends to be more pronounced in individuals with agenesis2121. Ranta R. A review of tooth formation in cleft lip/palate. Am J Orthod Dentofacial Orthop. 1986; 90: 11-8.. This may explain the absence of delayed dental development in the individuals with cleft lip and palate observed in this study. We excluded individuals who had agenesis and a possible greater probability of changes in dental development. On the other hand, Ruiz-Mealin et al.2222. Ruiz-Mealin EV, Parekh S, Jones SP, Moles DR, Gill DS. Radiographic study of delayed tooth development in patients with dental agenesis. Am J Orthod Dentofacial Orthop. 2012; 141: 307-14. (2012) observed delays in the dental development of subjects with agenesis and without any syndrome or medical condition (meaning without clefts). This may suggest that delayed dental development is more associated with the presence of agenesis than with cleft lip and palate.
There was a strong correlation between dental age and chronological age in the control and cleft groups. However, the dental age was advanced in relation to chronological age in the cleft and control groups with a statistically significant difference for both groups. This finding was also reported by other studies2323. Koshy S, Tandon S. Dental age assessment: the applicability of Demirjian's method in south Indian children. Forensic Sci Int. 1998; 94: 73-85.
24. Willems G, Olmen AV, Spiessens B, Carels C. Dental age estimation in Belgian children: Demirjian's technique revisited. J Forensic Sci. 2001; 46: 893-5.
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2525. Kýrzýoðlu Z, Ceyhan D. Accuracy of different dental age estimation methods on Turkish children. Forensic Sci Int. 2012; 216: 61-7. that aimed to estimate the chronological age by assessing the dental age using the method described by Demirjian et al.1414. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol. 1973; 45: 211-27. (1973). These results demonstrate that this method tends to overestimate the dental age when applied to different populations.
For the present study, however, this fact was not relevant, since the goal was not to estimate the chronological age from the dental age. The Demirjian et al.1414. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol. 1973; 45: 211-27. (1973) method was used with the purpose of comparing the dental age of individuals from cleft and control groups with the same chronological age.
No statistically significant difference in dental age between the cleft and control groups was found even when considering the different genders, cleft types and chronological age groups separately. Therefore, one can conclude that the analysis of dental development in individuals with cleft lip and palate should have the same approach used for individuals without clefts, with a focus on the individualization of diagnosis and treatment planning.
Acknowledgement
This work was supported by a Brazilian research funding agency (CAPES).
References
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1World Health Organization. Global strategies to reduce the health-care burden of craniofacial anomalies. Geneva: The Organization; 2002.
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2Freitas JAS, Garib DG, Oliveira TM, Lauris RCMC, Almeida ALPF, Neves LT, et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC/USP) - Part 2: pediatric dentistry and orthodontics. J Appl Oral Sci. 2012; 20: 268-81.
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3David DJ, Smith I, Nugent M, Richards C, Anderson PJ. From birth to maturity: a group of patients who have completed their protocol management. Part III. Bilateral cleft lip-cleft palate. Plast Reconstr Surg. 2011; 128: 475-84.
-
4Toscano D, Baciliero U, Gracco A, Siciliani G. Long-term stability of alveolar bone grafts in cleft palate patients. Am J Orthod Dentofacial Orthop. 2012; 142: 289-99.
-
5Farronato G, Kairyte L, Giannini L, Galbiati G, Maspero C. How various surgical protocols of the unilateral cleft lip and palate influence the facial growth and possible orthodontic problems? Which is the best timing of lip, palate and alveolus repair? Literature review. Stomatologija. 2014; 16: 53-60.
-
6Osawa T, Omura S, Fukuyama E, Matsui Y, Torikai K, Fujita K. Factors influencing secondary alveolar bone grafting in cleft lip and palate patients: prospective analysis using CT image analyzer. Cleft Palate Craniofac J. 2007; 44: 286-91.
-
7Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res. 1968; 47: 664.
-
8Loevy HT, Aduss H. Tooth maturation in cleft lip, cleft palate, or both. Cleft Palate J. 1988; 25: 343-7.
-
9Pham AND, Seow WK, Shusterman S. Developmental dental changes in isolated cleft lip and palate. Pediatr Dent. 1997; 19: 109-13.
-
10Borodkin AF, Feigal RJ, Beiraghi S, Moller KT, Hodges JS. Permanent tooth development in children with cleft lip and palate. Pediatr Dent. 2008; 30: 408-13.
-
11Brouwers HJM, Kuijpers-Jagtman AM. Development of permanent tooth length in patients with unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop. 1991; 99: 543-9.
-
12Heidbüchel KLWM, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJM. Dental maturity in children with a complete bilateral cleft lip and palate. Cleft Palate Craniofac J. 2002; 39: 509-12.
-
13Huyskens RWF, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Dental age in children with a complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006; 43: 612-5.
-
14Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol. 1973; 45: 211-27.
-
15Harris EF, Hullings JG. Delayed dental development in children with isolated cleft lip and palate. Arch Oral Biol. 1990; 35: 469-73.
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Publication Dates
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Publication in this collection
Oct-Dec 2014
History
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Received
07 Oct 2014 -
Accepted
16 Oct 2014