|Year : 2022 | Volume
| Issue : 3 | Page : 265-273
Comparison of craniofacial morphology characteristics along with dental caries status and salivary properties of operated cleft lip and palate patients with noncleft patients
Lipsikha Talukdar1, Sonali Saha1, Kavita Dhinsa1, Amit Rai1, Vandana Tiwari2, Himanshu Trivedi3
1 Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Biochemistry, Dr. RML Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Orthodontics and Dentofacial Orthopedics, Career Dental College, Lucknow, Uttar Pradesh, India
|Date of Submission||09-Jun-2022|
|Date of Decision||30-Aug-2022|
|Date of Acceptance||06-Sep-2022|
|Date of Web Publication||18-Oct-2022|
Professor & HOD, Department of Pedodontics and Preventive Dentistry Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Cleft lip and palate patients undergo many primary reconstructive surgical procedures which could lead to various changes in the facial morphology with growth. The most common diagnosis is unilateral cleft lip and palate (UCLP) and such patients are more prone to dental caries. Aims: This study aimed to evaluate and compare the lateral cephalometric landmarks, dental caries status, and salivary properties of surgically repaired UCLP children aged 6–15 years with lateral cephalometric landmarks, dental caries status, and salivary properties of noncleft children of the same age group. Materials and Methods: Twelve noncleft patients and 12 surgically repaired UCLP patients were chosen, and cephalometric analysis, salivary analysis, and dental caries status were recorded for both the groups. The data were then compared for both the groups. Statistical Analysis: It was analyzed using the Statistical Package for the Social Sciences (SPSS) version 21. The level of statistical significance was set at 0.05. Results: In surgical repair ULCP children, their was increased prevalance of dental caries along with decrease level of salivary calcium, Phosphorus,flow rate. Also, their was increased level of alkaline phosphatase, total protein level with acidic pH alongwith retruded maxillary complex with Class III malocclusion. Conclusion: Various primary reconstructive surgeries in UCLP children lead to maxillary retrusion with an increased prevalence of dental caries in these patients due to the maintenance of poor oral hygiene.
Keywords: Dental caries status, lateral cephalometric analysis, unilateral cleft lipand palate
|How to cite this article:|
Talukdar L, Saha S, Dhinsa K, Rai A, Tiwari V, Trivedi H. Comparison of craniofacial morphology characteristics along with dental caries status and salivary properties of operated cleft lip and palate patients with noncleft patients. J Indian Soc Pedod Prev Dent 2022;40:265-73
|How to cite this URL:|
Talukdar L, Saha S, Dhinsa K, Rai A, Tiwari V, Trivedi H. Comparison of craniofacial morphology characteristics along with dental caries status and salivary properties of operated cleft lip and palate patients with noncleft patients. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Nov 29];40:265-73. Available from: http://www.jisppd.com/text.asp?2022/40/3/265/358835
| Introduction|| |
Cleft lip and palate is the most common congenital anomaly which is caused by changes in morphologic pattern and alteration of growth factors together with deficiency of tissue in the maxillary palatal region. Due to the impediment of growth, these patients have either midface deficiency or tendency toward Class III malocclusion even after successive reconstructive surgeries. Operated patients generally present deformities in the craniofacial complex with a close relationship between supporting bony structures, morphology of the soft tissues, and space of the upper airway. To measure facial growth and to assess the effects of further treatment, the most effective and routine procedure is the cephalometric analysis. It provides significant clinical information regarding their orthodontic treatment. Apart from orthodontic problems, good oral hygiene maintenance is an arduous task in these children and hence they pose a risk of dental caries development. The association between dental caries and cleft lip palate in children is not clearly established, but studies infer a high prevalence of caries in cleft children. The higher vulnerability of dental caries in such patients is due to debilitated oral hygiene, early colonization of cariogenic microorganism, or enamel hypoplasia. Still, the importance of these risk factors has not been clearly stated.
Saliva plays a very important role in oral equilibrium maintenance and together with the oral microflora influences dental caries development. Different salivary components (salivary total proteins, salivary calcium, inorganic phosphorus and alkaline phosphatase, etc.) and salivary properties (regarding its flow rate, pH and buffering capacity, etc.) play a vital role in the induction and advancement of dental caries. The carious process can be reduced if these risk factors are identified early to enforce different preventive and interceptive procedures.
Currently, there is a paucity of scientific literature that evaluates and compares all these three parameters, i.e., saliva, cephalometric landmarks, and dental caries status, respectively, in surgically treated children with unilateral cleft lip and palate (UCLP).
Keeping this in mind, the present study was undertaken to evaluate and compare the lateral cephalometric landmarks, dental caries status, and salivary properties of surgically repaired UCLP children aged 6–15 years with lateral cephalometric landmarks, dental caries status, and salivary properties of healthy noncleft children of the same age group.
Materials and Methods
This cross-sectional study was conducted in the Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, in collaboration with Vivekananda Polyclinic and Institute of Medical Sciences (Smile Train Project), Lucknow, and the Department of Biochemistry, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow.
Sample size estimation
Sample size estimation was done using G Power( Chicago) software ( version 3.0). The sample size was estimated for t-test and the mean difference between two dependent means (matched pairs) was chosen. Minimum Sample size of 12 UCLP patients was found to be sufficient for an alpha of 0.05, power of 80%, 0.80 as effect size ( assessed for change in cephalometric parameters SNA and SNB from postoperative from a similar study).
The total sample size was decided as 24 (12 per group).
Twenty-four patients were divided into two groups (Group A and Group B). Group A comprised 12 surgically repaired UCLP children aged 6–15 years selected from the Outpatient Department, Vivekananda Polyclinic and Institute of Medical Sciences (Smile Train Project), Lucknow. Group B comprised 12 healthy noncleft children of the same age group selected from the Outpatient Department, Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh.
The inclusion criteria for selection of the participants in the study were as follows:
- Children who underwent primary surgical intervention for a confirmed diagnosis of UCLP
- Children aged 6–15 years
- Nonsyndromic children with no other associated craniofacial anomalies
- No previous history of orthodontic, orthognathic, or orthopedic treatments
- No previous history of airway infections or pharyngeal pathologies.
The exclusion criteria for rejection of the participants in the study were as follows:
- Uncooperative children
- Mentally challenged children
- Children with poor-quality pretreatment records
- Children undergoing orthodontic treatment, fixed or removable prosthesis
- If any of the parents of surgically operated UCLP patients disagree to sign a consent form.
The study design, objectives, and potential benefits were priorly explained to the selected children and their parents. Consent from the parents/guardians was obtained and Ethical Committee clearance was obtained from the Institutional Ethical Committee prior to the study. On the day of the first appointment, both parents and children were given an information sheet and were informed about the aim and the nature of the study. The sociodemographic data were collected from the study group which included name, gender, address, telephone number, and parents/guardians' name.
Previously, a pilot study was carried out in the same departments, to overview the proper study design and to take care of the possible constraints during the main study.
The study was divided into four phases:
Phase I: Lateral cephalometric analysis:
Lateral cephalometric radiographs were collected from the parents of the study group who were surgically repaired for their UCLP. For the control group, the radiographs were obtained from the parents of healthy children who were reported to the Department of Pedodontics and Preventive Dentistry for orthodontic treatment requiring lateral cephalometric radiographs. After collecting the radiographs, the tracing was done to determine skeletal (angular and linear), soft-tissue (angular and linear), and upper airway parameters [Figure 1]a and [Figure 1]b.
|Figure 1: (a) Lateral cephalometric landmark analysis of surgically repaired unilateral cleft lip and palate children. (b) Lateral cephalometric landmark analysis of healthy noncleft children|
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After tracing the cephalometric parameters, the values obtained for each parameter were tabulated in an Excel sheet and cephalometric analysis was done. After lateral cephalometric analysis, dental caries status was assessed (Phase II).
Phase II: Dental caries status assessment:
Examination of the oral cavity was done in a comfortable well-ventilated room during the day and whenever necessary an additional artificial light source (handheld battery-operated torch) was used. Individual cross-infection protection protocols were maintained.
Visual-tactile examination of dental surfaces was performed after cleaning with the aid of dental floss and prophylaxis with pumice/water paste. The teeth were then dried with the aid of air jet for 5 s. With the help of a WHO probe, the surfaces of anterior teeth at the cleft area and posterior teeth were examined starting from the maxillary right posterior quadrant toward the next quadrant at clockwise direction. During examination, if a deciduous tooth occupied the same space of a permanent tooth, the latter was examined. When more than one caries lesion was present on the occlusal surface, the severest lesion was classified and recorded [Figure 2]a and [Figure 2]b.
|Figure 2: (a) Intraoral picture of a cleft patient with dental caries. (b) Examination of dental caries using WHO probe|
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The International Caries Detection and Assessment System II (ICDAS-II) criteria were employed and dental caries was recorded when at least one tooth received code 2 or higher. Children having the aforementioned score were referred to the Department of Pedodontics, Sardar Patel Postgraduate Institute of Dental and Medical Sciences (Lucknow), for receiving preventive and comprehensive oral health care.
After collecting the ICDAS-II scores, the values obtained were tabulated in an Excel sheet and sent for statistical analysis to calculate the prevalence of dental caries.
After dental caries assessment, the physicochemical and biochemical analysis of saliva was performed simultaneously (Phase III and Phase IV).
Phase III (Physicochemical analysis of saliva) and Phase IV (Biochemical analysis of saliva):
For both the groups, to avoid bias of the saliva analysis, all subjects were instructed not to drink, eat, brush their teeth, or eat chewing gums for at least 1 h before examination. Physicochemical analysis of saliva (Phase III) was performed using a standardized kit “GC Saliva-Check BUFFER kit” (GC Corporation, Tokyo, Japan) to check for pH of saliva and salivary flow [Figure 3].
For biochemical analysis of saliva (Phase IV), unstimulated whole saliva was collected under resting condition using the method described by Scully (in this method, children were asked to spit in the glass vials once a minute for 10 min) [Figure 4].
|Figure 4: Unstimulated saliva expectorate being collected into measuring cup|
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Thereafter, salivary vials were delivered to the Biochemistry Laboratory of Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, for the estimation of salivary calcium, phosphorus, alkaline phosphatase, and total proteins:
- Salivary calcium was determined using a kit consisting of Arsenazo III reagent and calcium standard
- Salivary inorganic phosphorus was determined using the phosphomolybdate/ultraviolet method of Daly and Ertingshausen
- Salivary alkaline phosphatase was determined by the King Armstrong method (colorimetric method) in the presence of alkaline potassium ferricyanide
- Salivary total proteins were estimated by the colorimetric method treated with alkaline copper sulfate (CuSO4) and Folin–Ciocalteu reagent.
After completion of Phases I, II, III, and IV, all the tabulated data obtained in the respective phases were sent for statistical analysis.
Data were entered into Microsoft Excel spreadsheet and then checked for any missing entries. It was analyzed using the Statistical Packge for the Social Sciences ( SPSS, Chicago) version 21. Majority of the variables were continuous variables, which were summarized as mean and standard deviation. Graphs were prepared in Microsoft Excel. Inferential statistics were performed using independent t-test and Mann–Whitney U-test. For intergroup comparison of interval scale variables, independent t-test was used. Mann–Whitney U-test was used for intergroup comparison of the mean number of teeth having various ICDAS scores. The level of statistical significance was set at 0.05.
| Results|| |
[Table 1] shows the intergroup comparison of skeletal (angular) parameters among both the study and control groups. In the study group, the skeletal angular parameters SNA and ANB angles were found to be significantly lower while SNB and FMA angles were higher when compared to the control group.
[Table 2] shows that the majority of skeletal linear parameters (total facial height, sella-nasion, and gonion-gnathion) were significantly lower while the mean lower anterior facial height was significantly higher among the study group as compared to the control group.
When comparing the soft-tissue angular parameters [Table 3], the nasolabial angle and the angle of convexity were significantly lower in the study group.
All the soft-tissue linear parameters [Table 4] in the study group were found to be significantly lower as compared to the control group except the nasal length in which there was no statistically significant difference between the two groups.
On comparison of the upper airway space parameters [Table 5], all the parameters, i.e., posterior airway space (PAS), superior PAS (SPAS), inferior airway space (IAS), and epiglottic airway space (EAS), were significantly lower while the middle airway space (MAS) was significantly higher in the study group when compared to the control group.
[Table 6] shows the intergroup comparison of mean number of teeth having different ICDAS-II scores, and it was found that the mean number of teeth having ICDAS-II score 0 was significantly higher among the control group as compared to the study group. The mean number of teeth having ICDAS-II scores 1, 2, 3, 4, and 5 was found to be significantly higher among the study group as compared to the control group. The mean number of teeth having ICDAS-II score 6 did not differ significantly among both the groups.
[Table 7] shows the prevalence of dental caries (ICDAS-II score 2 as cutoff for dental caries for both the study and control groups). The prevalence of dental caries was 100.0% in the study group, while in the control group, it was found to be 66.6%.
|Table 7: Prevalence of dental caries (International Caries Detection and Assessment System-II score 2 as cutoff for dental caries)|
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[Table 8] shows the intergroup comparison of salivary parameters among both the study and control groups. The concentration of salivary alkaline phosphatase and total proteins was found to be significantly higher, and the concentration of salivary Ca, P, flow rate, and pH was found to be significantly lower among the study group as compared to the control group participants.
| Discussion|| |
Defects usually associated with cleft lip palate patients are those of growth in all three planes: vertical, sagittal, and transverse. These patients are generally characterized by possessing abnormalities of the dental arch form, malocclusion, and facial deformity. Apart from differences in craniofacial defects, the rehabilitation of cleft lip and palate patients is directly related to the oral condition, a prerequisite to perform reparative surgeries requiring infection-free environment to obtain satisfactory results. According to Vitor et al., there is a high caries disease prevalence in cleft lip and palate individuals. More accurate methods for correct dental caries lesion diagnosis would imply in reduced need for restorative treatment to remove the infection foci that may compromise reparative surgeries. According to Aizenbud et al., the constant communication between the oral and nasal cavities may cause a unique oral biological environment compared to normal individuals. This local disturbed anatomy in the presence of a craniofacial defect might influence the composition and flow rate of the saliva in the local aspect as well as in the systemic secretion by the salivary glands.
According to the results of the present study, the skeletal angular parameters, i.e., mean SNA and ANB, were significantly decreased and mean SNB and FMA were significantly increased among the study group as compared to the control group. This result was in accordance with studies by Corbo et al., Rullo et al. (2009), Liu et al. Akarsu-Guven et al., and Naqvi et al. (2015). According to them, this may be inferred to the fact that the effect of extensive surgical procedures performed to mobilize tissues to close a large defect may result in the formation of fibrous scar tissue near the sites of bone growth interfering with normal growth and development of the maxilla in a downward and forward direction in patients suggesting a retrusive maxilla in relation to the cranium.
For the skeletal linear parameters, total facial height (N-Me), anterior cranial base length (S-N), and gonion-gnathion length (Go-Gn) were found to be significantly decreased among the study group participants which were in accordance with studies by Fudalej et al., Liu et al., and Ravi. The authors stated that this could be due to the deviated craniofacial morphology after surgery deviated and attributed to mandibular downward and backward rotation. In addition, in our study, lower anterior facial height (ANS-Me) was significantly increased among the study group participants which were in support of the studies by Doğan et al. (2006), Moreira et al., and Kulshrestha et al. According to Doğan et al. (2006), the maxillary plane becomes more steeper after surgery, while the mandible compensates for the maxillary hypoplasia, becoming more retrusive. According to Moreira et al., this was compounded by the growth rotation of the mandible, which significantly showed less closure with growth in the surgically operated UCLP children. These growth changes highlighted the vertical growth pattern in these children. The present study revealed that the soft-tissue angular parameters (nasolabial angle and angle of facial convexity) were significantly decreased of the study group participants. Our results were similar to studies by Bearn et al. (2002), Fudalej et al. (2010), Liu et al., Dogan et al., and Kulshrestha et al. Bearn et al. (2002) stated that there was a disruption of the normal anatomy of the maxilla in these children and the soft-tissue profile resulted in a significantly decreased value of nasolabial angle due to both the original defect and the surgical correction leading to retrusion of upper incisors and flattening of the subnasal region. Fudalej et al. (2010) found that these children had a concave profile due to the compensation of mandible for the maxillary hypoplasia, decreasing the nasolabial angle. Kulshrestha et al. attributed that the lower values of nasolabial angle might be a result of nasal and lip deformities, its flattening, and its curvature to the cleft side. According to them, these deformities were usually accompanied by a shift of the point columella down, closer to the lips. The significant reduction of nasolabial angle might be caused by a larger deformity and retraction of the upper lip due to the reconstructive surgical procedures. Dogan et al. showed that the angle of facial convexity was decreased in surgically repaired UCLP children indicating serious maxillary retrognathism which could be the result of dysplastic influences from the increased labial pressure after closure of the lip and from scar tissue left by palatal repair.
The results of our present study showed a significant decrease in soft-tissue linear parameters (upper lip to S-line, lower lip to S-line, lower lip to SnV, upper lip to SnV, interlabial gap, upper lip length, lower lip length, and mentolabial sulcus) except nasal length among the study group children. Our study results were in support of the studies by Hermann et al., Liu et al., and Almoammar et al. (2000). According to Hermann et al. and Almoammar et al. (2000), the upper lip and lower lip positions were retrusive to all the reference lines (S-line and subnasal vertical line). This could be attributed to the fact that cleft lip and palate subjects have most of the teeth missing and the lower lip while attempting to achieve labial seal by touching the upper lip gets more retrusive with the presence of missing teeth by trying to follow its cranial base (the maxilla) which is retruded in cleft lip and palate subjects after primary reconstructive surgeries. The authors, additionally, observed in their study that the mentolabial sulcus was significantly shallower among the surgically operated cleft lip and palate subjects possibly because the lower lip was too stretched during the surgical procedures as it tried to be as close as possible to the upper lip, which was retrusive according to the S-line. They further stated that the upper and lower lip lengths decreased significantly with age among these surgically operated subjects due to the decreased bone support and overclosure of the upper lip during the surgical procedures resulting in decrease of the interlabial gap.,
According to the results of the present study, the dimension of the upper airway parameters PAS, SPAS, IAS, and EAS was significantly decreased while MAS was significantly increased among the study group participants. This was in support of the studies by Imamura et al., Aras et al., and Akarsu-Guven et al. The authors stated that due to palatal surgeries, the dimension of the parameters (PAS, SPAS, IAS, and EAS) was significantly decreased and MAS was significantly increased gradually with age in all stages of growth.
The results of our study showed that the prevalence of dental caries was significantly higher among the study group participants which was in accordance with the studies by Bian et al., Besseling and Dubois, Vitor et al., Sundell et al., Shashni et al., Veiga et al., and Kamble et al. Bian et al. attributed this increased prevalence to two important factors, i.e., bottle feeding of the child and educational attainment level of the mother. Kamble et al. pointed out that even after surgical repair, malposed, malformed, and missing teeth appeared more frequently in cleft lip and palate children and food entrapment and its prolonged retention upon the surfaces of malposed teeth were generally considered a predisposing cause for tooth decay. Implementing comprehensive preventive approaches addressing education, support, and compliance of parents/caregivers can lead to improved oral health, thus reducing the risk of caries in children with cleft lip/palate.
On physicochemical and biochemical salivary analysis, the present study showed significantly low salivary pH, flow rate, and decreased calcium and phosphorus levels in support of the studies by Leone and Oppenheim, Tulunoglu et al., Prabhakar et al., Preethi et al., Kaur et al., Shetty et al., Fiyaz et al., Ahmadi et al. (2000), Sejdini et al., and Almaeeni and Hasan. As cleft lip and palate patients are more prone to the occurrence of dental caries, therefore the authors stated that low pH and salivary flow rate were significant risk factors for caries development and were adequate to cause demineralization of inorganic substance of the tooth and dissolution of enamel. According to Prabhakar et al., the mean calcium level in caries active children was decreased attributing to the process of remineralization of the incipient caries lesions. Similarly, Fiyaz et al. attributed that the subjects with decreased levels of salivary calcium and phosphate are at a higher risk of developing dental caries, as their plaque is more acidogenic and demineralization of enamel occurs, resulting in less number of intact teeth in these individuals.
The results of the present study also revealed that salivary total proteins and alkaline phosphatase levels were significantly increased in the study group participants which were in support of the studies done by Hegde et al., Deshpande et al., and Almaeeni and Hasan. According to Almaeeni and Hasan, there was a significantly increased level of salivary total proteins in surgically repaired UCLP subjects which could be attributed to the fact that there are several common secreted proteins such as actin, salivary cystatins, keratins, and other keratinocyte-activating proteins upregulated by a cleft. Hence, the salivary total proteins are of vital importance in the general protection and tissue regeneration of patients with cleft lip and palate. Hegde et al. analyzed the relationship between dental caries and salivary alkaline phosphatase levels and stated that alkaline phosphatase has been considered to be an indicator of bone formation and is a phenotypic marker for osteoblasts cells. The rise in salivary alkaline phosphatase levels reflects inflammation and the destruction of healthy tissues resulting in the occurrence of dental caries suggesting it as an important biomarker.
| Conclusion|| |
The UCLP children after undergoing various primary and secondary reconstructive surgeries go through many changes in the facial morphology which results in retrusion of the maxilla leading to Class III malocclusion. As the child grows with age, this malocclusion has an ill effect on the whole face esthetically which may lead to temporomandibular joint problems. In these children, reduced access for cleaning upper anterior teeth after surgical repair leads to poor oral hygiene status, leading to increased risk to dental caries. Given the high caries experience among children with cleft lip and cleft palate, it is necessary to advocate a more rigorous approach to the prevention of dental disease in these high-risk children. It is essential that the patient with a cleft is monitored closely with regular dental care and maintained at all times.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]