ORIGINAL RESEARCH Root development of permanent lateral incisor in cleft lip and palate children: A radiographic study Deepti Amarlal, Muthu MS, Siva Kumar N
m rf o d ns a lo tio n w lica o d ub e rf e w P m). r fo kno .co le ed ow b la M dkn i a by e v a si ted w.m sanomaly.wChildren mandibular premolars is more frequent than other Cleft lip and palate is a common Fcongenital o with cleft lip and palateD have many and the congenitally missing teeth outside the cleft area in subjects whealth h problems, ( complexity of these problems requires numerous care with cleft lip, cleft palate or both. P e t practitioners to formis a cleft team. This multidisciplinary cleft si for the patient’s medical and Delayed eruption of permanent teeth in cleft lip and/or cleft lip and palate teamhis responsible T faciala esthetics and psychological well- palate patients was reported by Bailit et al. in 1968. Prahl general development, Dept. of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India
Received
ABSTRACT
: 25-08-05
Review completed: 08-01-07 Accepted : 22-01-07 PubMed ID
: ???
Objective: The objective of this study was to compare the root development of lateral incisor on the cleft side with the root development of its contralateral tooth in cleft lip and palate children. Setting: Cleft lip and palate wing, Meenakshi Ammal Dental College and Hospital, Chennai, South India. Materials and Methods: A sample of 96 orthopantamograms of patients with unilateral or bilateral cleft lip and/or cleft palate was selected, regardless of sex and race. Main Outcome Measure: Orthopantamograms were analyzed for root development of lateral incisor on the cleft and noncleft side. Associated anomalies like hypodontia, supernumerary teeth, malformed lateral incisors and root development of canine, if present, were recorded. Findings and Conclusions: Root development of permanent lateral incisor was delayed on the cleft side compared to the noncleft side. There was a statistically significant relationship between levels of root development of lateral incisors on the cleft side within the different study groups (P < 0.05). Incidence of hypodontia increased in proportion to cleft severity. Frequency of missing second premolars, supernumerary teeth and malformed lateral incisors increased in cleft lip and palate patients. Root development of canine showed a slight delay on the cleft side when compared to the canine on the noncleft side. Key words: Cleft lip and palate, hypodontia, permanent lateral incisor, root development
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being, hearing and speech development. Numerous dental anomalies occur with cleft lip and palate, namely, hypodontia, supernumerary teeth, microdontia, fused teeth, ectopic eruption, posterior crossbites, pseudoprognathism and the like. These defects may be attributed to the cleft itself or to the early surgical correction of the defects. Ranta in 1972[1] reported that congenital absence of the cleftside permanent lateral incisor is the most common finding in children with cleft lip, cleft palate or both. Supernumerary teeth in the cleft region is the second most common anomaly, followed by hypodontia. Hypodontia of the maxillary and Correspondence: Dr. Deepti A. E-mail:
[email protected] Indian J Dent Res, 18(2), 2007
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and Anderson in 1979 reported delayed dental development in boys alone until the age of 9 years. Loevy and Aduss in 1988[4] have reported precocious development of teeth in boys with cleft. Ribiero et al. in 2002[5] were the first to compare the root development of permanent lateral incisor on the cleft side with its contralateral tooth in subjects with unilateral cleft lip and palate. They found that the root development of permanent lateral incisor on the cleft side was delayed when compared with its contralateral tooth. In a study by Dewinter et al. in 2003,[6] hypodontia of lateral incisor was found in 58.6% of the patients. Hypodontia of teeth outside the cleft area was found to be 27.2%. Ribiero et al. in 2003[7] reported that congenital absence of lateral incisor on the cleft side was observed in 49.8% of the patients. The cleft side permanent lateral incisor was present in 50.2% and was more commonly 82
Root development of permanent lateral incisor
Deepti, et al.
located at the distal (76.5%) than the mesial (23.5%) side of the cleft. Hypodontia outside the cleft area was 20.7% on the cleft side and 15.7% on the noncleft side. Supernumerary teeth were observed in 6.4% of the sample.
This data was sent for statistical analysis. The assessment of all orthopantamograms was done by a single examiner. To assess the accuracy of the examiner, 15 randomly selected orthopantamograms were reassessed and statistically analyzed.
The purpose of this study was to compare the root development of the lateral incisor on the cleft side to that on the noncleft side in south Indian children. The incidences of other dental anomalies like missing teeth, supernumerary teeth and malformed teeth were recorded. The difference between the development of canine on the cleft side and that on the noncleft side was also noted.
1 Spearman rank test was done for correlation analysis of cleft and noncleft scores. 2 Pearson’s Chi-square test was used to calculate the ‘P ’ value for associated anomalies. 3 One-way ANOVA was used to calculate the mean values of age of different study groups. 4 Pearson’s Chi-square test and Fisher’s exact test were used to find out the distribution of missing teeth. 5 Kruskal-Wallis one-way ANOVA and Mann-Whitney U test were used to calculate the mean cleft scores. 6 Intra-examiner variability was assessed using intra-class correlation coefficient.
m o This study was carried out in the cleft lip and palate wing of fr the Oral and Maxillofacial Surgery Department in Meenakshi d ns Ammal Dental College, Chennai, India. Three hundred a RESULTS orthopantamograms were evaluated from the data bank of lo tio n the cleft lip and palate wing. Among the 300 agroups was done under the wthe four orthopantamograms, 100 orthopantamograms of children in Comparison between c i o l the 6-16 years age group were selected. The selection criteria following parameters: d ub included the presence of unilateral or bilateral cleft lip and/or e for cleft P side and).noncleft side, hypodontia of cleft palate. Subjects were not excluded based on sex or ethnic Age, sex, scores e r background. Four orthopantamograms were excluded lateral fincisor and associated anomalies. There was no w m r because of lack of clarity. The remaining 96 significant difference between mean ages of different study o co fo (P k= n0.90). orthopantamograms were checked under adequate groups . illumination for the stage of development of lateral incisor le w d and canine on the cleft side and noncleft side based on Nolla’s b Mean,estandard o deviation and test of significance of mean n li a values stages. Associated anomalies like hypodontia of lateral of cleft-side Nolla’s score for lateral incisor in different M groups k d incisors, hypodontia of premolars and supernumerarya teeth study were - Group 1: 5.8 ± 3.5, Group 2: y eGroup 3: as3.6follows ± 3.4, Group 4: 3.9 ± 4.1. were also recorded. The presence of permanent lateralvincisor b 2.0 ± 2.2, a d .m on the cleft side was determined by a criterion established by s one-way ANOVA test was used to calculate Damante et al. in 1973, according to which a ilateral incisor te Kruskal-Wallis w F is defined as a single tooth in the vicinity of the cleft,sin the wthe ‘P ’ value. Mann-Whitney U test with Bonferoni correction o or as aw method was employed to identify significant groups at 5% mesial or distal side, accepting any toothD morphology; h ( level. tooth in the mesial side with anotherP one in e the distal side, it which was considered as a supernumerary is stooth. h was no significant difference in mean cleft side scores aname, age, sex, type There A proforma was prepared, inT which the between different study groups at 5% level. Mean, standard MATERIALS AND METHODS
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of cleft and Nolla’s stages of development of lateral incisor and canine were entered in separate columns. The numerical value corresponding to the Nolla’s stage of development for lateral incisor was entered both on the cleft and the noncleft side. In subjects where there was difference in the development of canine on the cleft side and noncleft side, such difference was noted and those values were recorded in the pro forma. Other associated anomalies like hypodontia of premolars, supernumerary teeth and malformed incisors were also recorded. Once this data was collected, it was divided into four groups as follows: Group 1 - Unilateral cleft lip and alveolus Group 2 - Bilateral cleft lip and alveolus Group 3 - Unilateral cleft lip and palate Group 4 - Bilateral cleft lip and palate 83
deviation and test of significance of mean values of noncleft side for lateral incisor in different study groups were as follows - Group 1: 8.9 ± 1.9, Group 3: 8.7 ± 1.9. Kruskal-Wallis one-way ANOVA test was used to calculate the ‘P ’ value. Mann-Whitney U test with Bonferoni correction method was employed to identify significant groups at 5% level. Mean, standard deviation and test of significance of mean values of cleft-side Nolla’s score for canine in different study groups were as follows - Group 1: 7.4 ± 0.9, Group 3: 7.2 ± 1.3 of the cleft, compared with its contralateral tooth, in the south Indian population attempted to determine the differences in the root development in cleft lip and palate Indian J Dent Res, 18(2), 2007
Deepti, et al.
Root development of permanent lateral incisor
Mann-Whitney U test was used to calculate the ‘P ’ value. There was no significant difference in the mean cleft-side canine scores between Groups 1 and 3 (P = 0.78).
of the cleft, compared with its contralateral tooth, in the south Indian population attempted to determine the differences in the root development in cleft lip and palate patient.
Mean, standard deviation and test of significance of mean values of noncleft side for canine in different study groups were as follows - Group 1: 8.6 ± 0.5, Group 3: 8.3 ± 1.2.
Demerijian et al. in 1973[10] observed that mechanisms controlling dental development are independent of somatic and sexual maturity and seem to be highly influenced by the same etiological factors as the cleft. In this study, the cleftside lateral incisor, if present, was compared for its root development with the noncleft side using Nolla’s rating system. The degree of root development on the cleft side and noncleft side was similar in both the sexes. This is in agreement with studies done by Solis et al. in 1998[11] and Ranta et al. in 1972.[1] There was a statistically significant difference in the mean values between the cleft and the noncleft sides, indicating a delay in the root development
Mann-Whitney U test was used to calculate the ‘P ’ value. There was no significant difference in mean noncleft side canine scores between Groups 1 and 3 (P = 0.63).
m rf o d ns a lo tio DISCUSSION n w lica o This study of lateral incisor root development in the vicinity d ub e rf e w P m). r fo kno .co le ed ow b la M dkn i a by e v a si ted w.m F os w D P te h (w is si h T a
Correlation analysis of cleft and noncleft scores for lateral incisor and canine, distribution of missing teeth supernumerary teeth, and malformed lateral incisors, and repeatability analysis are to tabulated [Tables 1-8].
Table 5: Distribution of missing premolars in different study groups Group
Table 1: Correlation analysis of Nolla’s scores for lateral incisors
Group Correlation coefficient* (r) P - value Unilateral (n = 77) 0.44 < 0.0001 (Sig.) Bilateral (n = 19) 0.98 < 0.0001 (Sig.) *Reported value is Spearman rank correlation coefficient
Table 2: Correlation analysis of Nolla’s scores for canines
P - value < 0.0001 (Sig.)
Group Correlation coefficient* (r) Unilateral (n = 14) 0.96
1 2 3 4
(n (n (n (n
= = = =
31) 5) 46) 14)
Group
1 2 3 4
(n (n (n (n
= = = =
31) 5) 46) 14)
Missing teeth - cleft side Yes No 9 22 4 1 27 19 9 5
P - value*
Significant# groups at 5% level
0.02 (Sig)
1 vs. 21 vs. 3
Table 6: Distribution of supernumerary teeth in different study groups Group
Table 4: Distribution of missing teeth in different study groups Group 1 2 3 4
(n (n (n (n
= = = =
31) 5) 46) 14)
Nil 22 1 19 5
Missing teeth One side Both sides 9 0 0 4 26 1 0 9
(n (n (n (n
= = = =
31) 5) 46) 14)
Supernumerary Yes 1 1 1 2
P - value*
teeth No 30 4 45 12
0.13 (NS.)
*Pearson’s Chi-square test was used to calculate ‘P ’ value.
Table 7: Distribution of malformed lateral incisors in different study groups
1 2 3 4
(n (n (n (n
= = = =
31) 5) 46) 14)
Malformed lateral incisors Yes No 13 1 8 0 5 5 41 3 11
P - value*
Significant # groups at 5% level
0.008 (Sig)
1 vs. 3
*Pearson’s Chi-square test was used to calculate ‘P’ value, #Fisher’s exact test (2-tailed) or Chi-square test with Yates continuity correction was employed to identify the significant groups at 5% level.
P - value* < 0.0001 (Sig)
*Pearson’s Chi-square test was used to calculate ‘P ’ value.
Indian J Dent Res, 18(2), 2007
1 2 3 4
Group
*Pearson’s Chi-square test was used to calculate ‘P ’ value, #Fisher’s exact test (2-tailed) or Chi-square test with Yates continuity correction was employed to identify the significant groups at 5% level.
0.27 (NS.)
*Pearson’s Chi-square test was used to calculate ‘P ’ value.
*Reported value is Spearman rank correlation coefficient.
Table 3: Distribution of missing teeth on cleft side in different study groups
P - value*
Missing premolars Yes No 1 30 1 4 5 41 0 14
Table 8: Repeatability analysis for n = 15 cases Variable
Intra-class correlation coefficient (95% C.I.) Cleft score 0.91 (0.73 - 0.97) NonCleft score 0.97 (0.90 - 0.99)
P - value 0.13 (NS.) < 0.0001 (Sig.) 84
Deepti, et al.
Root development of permanent lateral incisor
for the cleft side lateral incisor [Figure 1]. This asymmetry has been noted by Ranta in 1972,[1] Solis et al. in 1998[11] and also in a similar study by Ribiero et al. in 2002.[5] According to Solis et al. in 1998[11] and Peterka et al. in 1993,[12] this delay in root development occurred because of the same factors that are responsible for the formation of cleft. Other factors have also been proposed to account for this delay, including surgery around the cleft side according to Ranta in 1972,[1] nutritional factors according to Ranta in 1972[1] and Solis et al. in 1998,[11] a prenatal insult interacting with a poorly buffered genotype according to Bailet et al. in 1968[2] and lack of bone support according to Peterka et al. in 1996. [12]
Figure 1: Orthopantamogram (Group 1) showing supernumerary tooth. Permanent lateral incisor on the right side is at Nolla’s stage 8 and the contralateral tooth is at Nolla’s stage 9
m o fr d ns a There was statistically significant difference when hypodontia lo tio n rates of the permanent lateral incisor for the cleft and noncleft w lica sides were compared [Figure 2]. Proportion of missing teeth o on the cleft side in Group I was 29%, and on the noncleft side d ub it was 0%. Proportion of missing teeth in Group 3 on the cleft e P ). side was 58.7%, and on the noncleft side it was 2.2%. e r Proportion of missing teeth in Group 2 and Group 4 was 80.0% f w m r and 64.3% respectively. This is in agreement with a similar o no .co study done by Ribiero et al. in 2003. This hypodontia can be f k w attributed to any of the following factors: the vicinity of the le d cleft according to Jiroutova and Mullerova in 1994 ; the b e no deficiency of blood supply, either congenital or secondaryla to i y M dk surgery, according to Vichi and Franchi in 1995 ora even e deficiency in the mesenchymal support according tovTsai et b al. in 1998. Brattstrom and McWilliams ina1989 d m ein w. reported that the prevalence of hypodontiais increases t s of w proportion to cleft severity. In our study, the F proportion o missing teeth in Group 3 and Group D 4 was higher when compared to Groups 1 and 2. P te h (w ismaxillarysiand medial nasal The absence of fusion between the h Ta deficiency a of mesenchymal processes, possibly because of In this study, the root development of canine showed a slight delay on the cleft side when compared to the canine on the noncleft side.
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Figure 2: Orthopantamogram (Group 2) showing missing right and left permanent lateral incisors and missing right mandibular second premolar
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[15]
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mass, could result in the cleft lip, cleft palate or both, and it is probable that the lateral incisor odontogenic potential comes from both these regions. This hypothesis, supported by Tsai et al. in 1998,[15] could explain the hypodontia of lateral incisor, its location at the distal or mesial side and the presence of a supernumerary tooth.
Figure 3: Orthopantamogram (Group 3) showing malformed left permanent lateral incisor and a supernumerary tooth. Right maxillary permanent canine is in Nolla’s stage 8 and left maxillary permanent canine is in Nolla’s stage 7
In our study, the frequency of missing premolars is 7.2%, which is slightly lower compared with 18% missing premolars reported by Shapira et al. in 1999[17] in their sample of cleft lip and palate individuals.
was found to be more in Group 1. This is because Group 1 is the least severe of the four groups.
The frequency of supernumerary teeth was found to be 5.2% and was equally distributed among the four groups [Figure 3]. The frequency of malformed lateral incisors was 21.8% and
Knowledge of developmental delay of lateral incisor on the cleft side is of value for determining the secondary bone graft placement on the basis of degree of root development, as proposed by Solis et al. in 1998.[11] Because of the higher
85
Indian J Dent Res, 18(2), 2007
Deepti, et al.
Root development of permanent lateral incisor
frequency of missing lateral incisors and second premolars found in cleft lip and palate children, it is important to determine at an early age the presence or absence of all permanent teeth and formulate an early treatment plan.
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m rf o d ns a lo tio n w lica o d ub e rf e w P m). r fo kno .co le ed ow b la M dkn i a by e v a si ted w.m F os w D P te h (w is si h T a 15.
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How to cite this article: Deepti A, Muthu MS, Siva Kumar N. Root development of permanent lateral incisor in cleft lip and palate children: A radiographic study. Indian J Dent Res 2007;18:82-6. Source of Support: Nil, Conflict of Interest: None declared.
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