Article_7_3_4-1
www.stomaeduj.com ORTHODONTICS
EVALUATION OF UPPER ARCH CHANGES IN PATIENTS
Original Articles
WITH UNILATERAL CLEFT LIP AND PALATE AFTER
MAXILLARY EXPANSION USING DIGITAL DENTAL CASTS
Fabrizia d’Apuzzo1a , Ludovica Nucci1b , Abdolreza Jamilian2c , Rosario Rullo1d , Vincenzo Grassia1e , Letizia Perillo1f*
1
Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
2
Department of Orthodontics, Islamic Azad University, Tehran, Iran
a
DDS, MS, PhD, Research fellow; e-mail: fabriziadapuzzo@gmail.com; ORCIDiD: https://orcid.org/0000-0003-0291-9339
b
DDS, PhD student; e-mail: ludortho@gmail.com; ORCIDiD: https://orcid.org/0000-0002-7174-7596
c
DDS, MSc, OMFS, Full professor; e-mail: info@jamilian.net; ORCIDiD: https://orcid.org/0000-0002-8841-0447
d
MD, MS, Associate professor; e-mail: rosario.rullo@unicampania.it; ORCIDiD: https://orcid.org/0000-0002-5418-8171
e
DDS, MS, PhD, Lecturer; e-mail: grassiavincenzo@libero.it; ORCIDiD: https://orcid.org/0000-0002-6671-2380
f
MD, MS, PhD, Professor, Head, Dean; e-mail: letizia.perillo@unicampania.it; ORCIDiD: https://orcid.org/0000-0001-6175-7363
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(3).art.4
Objective To compare the upper arch dimensions of young patients with unilateral cleft lip and palate
(UCLP) before and after treatment with bonded maxillary expander and hybrid activation protocol using
digital dental casts.
Methods Sixteen subjects with UCLP, aged between 7 and 14 years (mean age 10.9 ± 2.7 years) consecutively
treated with bonded maxillary expander and hybrid activation were included. The dental casts before and
after treatment were digitalized using a 3Shape scanner. Intercanine, interpremolar and intermolar widths
(at cusp and gingival levels) and arch perimeters were measured. The significance level for statistical analyses
was set as p < 0.05.
Results The total treatment time using the hybrid expansion protocol lasted 12 ± 1.9 months while the active
expansion time lasted 4 ± 0.2 months. Patients with UCLP showed significant differences in all transverse
upper arch dimensions both at cusp and gingival level.
Conclusion The use of a bonded maxillary expander with a hybrid activation protocol during growth may be
efficient to improve all transverse upper arch widths in patients affected by UCLP.
KEYWORDS
Cleft Lip and Palate; Maxillary Expansion; Bonded Expander; Hybrid Expansion Protocol; Digital Dental Casts.
1. INTRODUCTION morbidity and mortality throughout life compared
to noncleft subjects [5]. Oral rehabilitations usually
Cleft Lip and Palate (CLP) is one of the most common require complex and challenging interdisciplinary
types of congenital craniofacial birth anomalies due treatments since the first post-birth weeks do not
to environmental, genetic and epigenetic risk factors allow the most adequate early recovery of vital
interacting among them [1-3]. functions [5,6].
They can occur between the fourth and twelfth week Craniofacial growth harmony in patients with
of gestation due to the failure of fusion between unilateral or bilateral CLP is affected in all 3
the medial nasal and maxillary processes in the dimensions (3D). Previous studies showed that it
primary palate or the palatal units in the secondary can be only partially improved after surgery during
palate [4]. Affected patients need interdisciplinary childhood [7-9]. Lip surgery is usually performed at
care since birth until adulthood and evince higher 6 months of age using the Delaire technique, soft
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: d’Apuzzo F, Nucci L, Jamilian A, Rullo R, Grassia V, Perillo L., Evaluation of upper arch changes in patients with unilateral cleft lip and palate
after maxillary expansion using digital dental casts. Stoma Edu J. 2020;7(3):184-190.
Received: May 29, 2020; Revised: June 05, 2020; Accepted: June 07, 2020; Published: June 09, 2020
*Corresponding author: Prof. Letizia Perillo; Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi
Vanvitelli, via L. De Crecchio 6, 80138 Naples, Italy
Tel./Fax: +39 3334027273; e-mail: letizia.perillo@unicampania.it
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
184 Stoma Edu J. 2020;7(3): 184-190 pISSN 2360-2406; eISSN 2502-0285
Upper arch changes in patients with CLP after maxillary expansion
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Original Articles
Table 1. Age, treatment time and sex ratio of the UCLP patients.
Variable Mean SD
Initial age (years) 10,9 2,7
Total Treatment time (months) 12,0 1,9
Active Treatment time (months) 4,0 0,2
Sex Female 10
Male 6
Table 2. Random and systematic errors of the measurements performed on the digital dental models.
T0 T1
Systematic Systematic
Measurements D Dahlberg D Dahlberg
error P level error P level
3-3 cusp 1.30 NS 1.55 NS
3-3 gingival 1.24 NS 0.78 NS
4-4 cusp 0,89 NS 1.56 NS
4-4 gingival 1.50 NS 1.34 NS
5-5 cusp 1.45 NS 2,01 NS
5-5 gingival 1.67 NS 1.34 NS
6-6 cusp 1.07 NS 1.67 NS
6-6 gingival 0.98 NS 0.87 NS
AP 4.06 NS 1.81 NS
*p < 0.05, **p < 0.005
palate surgery at 12 months and hard palate surgery formation, as reported in normal patients [23].
at 18 months, whereas secondary alveolar bone However, to the best of our knowledge, there are
graft is usually planned when the patient is around no studies treating subjects affected by CLP using a
9 to 12 years old [10-12]. When the surgical protocol bonded maxillary expander with a hybrid activation
for the hard palate closure is delayed, the occlusion [24-27]. The bonded expander seems to have some
is even more affected [12]. advantages such as better control of vertical growth,
During the early mixed dentition, the maxillary arch reduced interocclusal interferences and less dental
linear dimensions significantly differ between the tipping due to acrylic splints covering both occlusal,
unilateral cleft lip and palate (UCLP) group and the buccal and palatal surfaces of teeth [28-30]. Many
noncleft group, [13] while the intercanine width papers conducted the palatal analysis of patients
seems to be more reduced in bilateral complete with CLP as compared to controls using novel three-
clefts due to scars resulting from palatal surgery [14]. dimensional (3D) technologies [31-33]. Nowadays,
It has been also demonstrated that children with the use of digital models is considered useful for
UCLP usually suffer from a nasomaxillary complex treatment planning and outcome evaluations and
deficiency which continues worsening until the end the reliability of measurements from 3D dental casts
of their growth and have maxillary dental arches as compared to those obtained directly from plaster
constricted in width and length [15]. models is evidence-based [34]. Thus, the purpose of
Thus, it is suggested to ideally start to perform an this study was to evaluate upper arch dimensions
early dentofacial orthopedic treatment protocol on digital dental casts in young patients with UCLP
during the mixed dentition [16]. In the light of these before and after treatment using a bonded maxillary
findings, an interceptive treatment with a palatal expander with a hybrid activation.
expander is usually proposed as a first approach [17-
19]. The palatal expander allows to correct transverse 2. METHODOLOGY
skeletal maxillary constriction and dental posterior
crossbite [20]. There are several different maxillary This retrospective observational study was based on
expansion modalities based on the appliance design the analysis of data collected from patients with UCLP
[21] or the type of activation and no differences were who had completed an orthodontic treatment with
found between slow or rapid expansion protocols in maxillary expansion at the Orthodontic Program of
children with bilateral CLP [17,22]. Thus, the positive the University of Campania Luigi Vanvitelli, Naples,
effects on the occlusion are undeniable in patients Italy. The research was carried out in accordance
with CLP modifying the upper arch diameters with the Declaration of Helsinki and approved by
and stimulating the transversal skeletal growth, the ethics committee of the University of Campania
even without leading to the same amount of bone Luigi Vanvitelli, Naples, Italy (Prot. N°147). An
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d’Apuzzo F, et al.
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Original Articles
Figure 1. Intraoral photograph of bonded maxillary expander in a Figure 2. Assessment on the digital model of arch widths: at the cusp
patient with UCLP. (yellow lines) and gingival (orange lines) level.
informed consent was obtained from the parents of arch were considered: transverse intercanine (3-3),
each patient. Here are the inclusion criteria: patients interpremolar or interdeciduous molar (4-4 and 5-5)
affected by UCLP, age ranging between 7 and 14 and intermolar (6-6) distances at both cusp tips and
years, constricted upper arch, cervical vertebral gingival levels, and arch perimeter (AP) calculated
maturation between CS1 and CS4 and treatment as circumference of the dental arch, measured from
protocol including a bonded maxillary expander with the distal surface of the maxillary permanent first
hybrid activation [24,26]. Subjects with other cranio- molars on the right side to the distal surface of the
facial syndromes, previous orthodontic treatment or contralateral ones.
incomplete documentation were excluded.
All patients had been previously treated at the 2.1. Statistical analysis
Division of Maxillofacial Surgery at the University of The reliability of the measurements was determined
Campania Luigi Vanvitelli, Naples, Italy, by the same by randomly selecting five dental casts before and
surgeon, using the same protocol and method as after the expansion treatment. They were measured
follows: lip surgery at 6 months, soft palate surgery at twice after a two-week interval. Dahlberg’s formula
12 months and hard palate surgery at 18 months. No was used to quantify the measurement error. An
infant orthopaedics was carried out prior to surgery. Intraclass Correlation Coefficient was also calculated
The initial (T0) and after expansion (T1) plaster to assess test/retest reliability. An unpaired t-test and
models of each patient were collected to be digita- a Wilcoxon signed-rank test were utilized to evaluate
lized and then analyzed [35]. any significant difference before and after treatment.
The treatment was performed with a bonded palatal The statistical significance was set at p <0.05.
expander (Fig.1) [16] applied on the upper lateral All statistical analyses were performed with SPSS
teeth. The activation started after the appliance software (Statistical Package for the Social Sciences,
onset and ended when overcorrection was achieved. SPSS, Version 12, Chicago, IL, USA).
The protocol used had two phases: the initial phase
started at the chair side and included three steps 3. RESULTS
with four, two and one turn, respectively; the second
one followed at home with one turn every 3 days [24, The total sample included 16 patients, 10 females
26]. During the active expansion phase depending and 6 males. The initial mean age was 10.9 ± 2.7 years.
on the degree of maxillary constriction, the patients The total treatment phase with the bonded expander
were monitored every 2 weeks. (T0-T1) lasted 12.0 ± 1.9 months while the active
After the active expansion phase, the screw of the expansion phase was 4.0 ± 0.2 months (Table 1).
appliance was closed with acrylic composite and The statistical analysis confirmed that there were
the expander was used as a retainer for about 8 no systematic measurement errors before and after
months. The expander was removed after about treatment, as shown in (Table 2).
1 year and a second plaster model was realized. Comparing measurements at T0 and T1 showed
Both dental casts were scanned using the 3shape statistically significant differences in all transverse
TRIOS®, with a reported manufacturing accuracy arch widths while arch perimeter values revealed no
of less than 20 microns (www.3shape.com), by the differences (Table 3).
same trained operators. The digital models were As to the difference arch diameters at both cusp tips
exported in STL surface mesh then imported in and gingival levels (Table 4), data showed statistically
Viewbox 4 (dHal Software, Kifissia, Greece). A total significant differences only for the diameter 3-3
of nine linear measurements of the upper dental measured at cusp level.
186 Stoma Edu J. 2020;7(3): 184-190 pISSN 2360-2406; eISSN 2502-0285
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Original Articles
Table 3. Measurements before (T0) and after maxillary expansion (T1).
T0 mean value T1 mean value
Variable STD Error t S
(mm) (mm)
3-3 cusp 26,72 31,36 1,59 0,01* 0,01*
3-3 gingival 21,72 24,81 1,38 0,04* 0,04*
4-4 cusp 34,18 40,05 1,73 0,004** 0,006*
4-4 gingival 23,08 28,43 1,51 0,003** 0,007*
5-5 cusp 40,68 46,40 1,92 0,009* 0,01*
5-5 gingival 26,94 33,16 1,82 0,004** 0,005**
6-6 cusp 49,90 55,79 1,65 0,003** 0,002*
6-6 gingival 32,76 38,65 1,55 0,002** 0,003**
AP 88,76 88,41 3,18 0,91 0,61
*p < 0.05, **p < 0.005
Table 4. Mean differences between measurements at the cusp and slow and rapid activation through Quad-helix and
gingival level of arch widths, before and after maxillary expansion. Hyrax expanders, respectively, in children with
bilateral CLP, showed differences only with respect
Mean
Variable difference STD Error t S to the treatment time. Specifically, the expansion
T1-T0 (mm) active phase ranged from 4 to 21 months in the
3-3 - 1,54 0,41 0,002** 0,004** slow protocol and from 7 to 14 days in the rapid
one [17,22]. Façanha et al. [20] assessing the effects
4-4 - 0,52 0,48 0,29 0,53
achieved with the Haas and Hyrax expanders using
5-5 0,50 0,59 0,41 0,77
a rapid protocol in patients with UCLP, highlighted
6-6 0,00 0,39 0,98 0,95 similar increases of the transverse dimensions. Ayub
*p < 0.05, **p < 0.005
et al. [39] performing the expansion with a rapid
protocol, found significant increases of all maxillary
4. DISCUSSION measurements including arch perimeter probably
due to the sample selection based on patients with
Several previous studies showed significant different a posterior crossbite. Conversely, in our study, this
maxillary morphologies in patients with CLP in mixed parameter did not change significantly. However, a
or permanent dentition when compared to matched direct comparison of our findings with other studies
controls before any orthopedic/orthodontic was only partially possible due to the differences
treatment [31-33,36]. In particular, the upper inter- in cleft features and size, patients’ age, dentition
canine widths significantly decreased both at cusp period, expansion appliance and protocol as well
and gingival levels [13-15,37]. Therefore, there is as the data analyses performed. Nevertheless, our
a complete agreement on the need to expand treatment outcomes may add a missing piece in the
the maxillary arch in patients affected by CLP. The puzzle about maxillary arch changes after expansion
reasons to use an expander in the orthodontic treat- treatment, underlying the possibility to achieve
ment plan are manifold. Iwasaki et al. [38] found that similar effects in a reduced time with a different type
the nasal airway flow significantly improved after of expander and activation [16,24-26]. Our results
rapid maxillary expansion in patients with UCLP confirmed the need for orthodontic treatment
increasing both the quantity of airflow and nasal during the development of the permanent dental
cross-sectional area on the cleft side. Also, speech occlusion and showed increases in all transverse
and deglutition enhance after expansion due to upper arch dimensions. Moreover, the bonded
wider space for the tongue, [6,33] but, above all, the expander seemed to exert a more homogeneous
occlusal relationships result improved by widening lateral pressure on the two halves of the maxilla
the palatal dimensions [18]. avoiding any possible interference of the lower
Many investigations focused on dental and alveolar arch due to the smooth acrylic splints covering
changes in patients with BCL and UCLP using diffe- the occlusal surface. Thus, the bonded expander
rent appliances and protocols. Our results have along with the hybrid activation protocol should
shed light on a different expansion appliance and be suggested in UCLP as a procedure to achieve
protocol in patients with UCLP. Pugliese et al. [21] an efficient maxillary expansion with arch widths
found that the maxillary expansion with Hyrax, homogeneous increase avoiding buccal tipping
Quad-helix and Expander with Differential Opening of premolars and molars maintaining an adequate
(EDO), in bilateral CLP patients, had similar changes active treatment time, of about 4 months, in the
in arch size, whereas only Quad-helix expander middle between the slow and rapid protocol [17,22].
and EDO were associated with a greater shape at This investigation, of course, had some limitations
the intercanine area. Other researchers, comparing such as the retrospective nature of the study design
Stoma Edu J. 2020;7(3): 184-190 pISSN 2360-2406; eISSN 2502-0285 187
d’Apuzzo F, et al.
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with short-term outcomes, currently lacking long- CONFLICT OF INTEREST
Original Articles term data [23]. Moreover, some subjects with UCLP
The authors declare no conflict of interest.
had some permanent teeth missing in the dental
arch on one or both sides. AUTHOR CONTRIBUTIONS
The elimination of these patients, however, may
have introduced higher selection bias eliminating Made substantial contributions to conception and design of the
more severely affected subjects with smaller arch study and performed data analysis and interpretation: FdA, VG, LP.
widths which is actually a common clinical frame of Performed data acquisition, as well as provided administrative,
CLP anomalies. technical, and material support: LN, AJ, RR.
Future studies should be planned with an increased
FINANCIAL SUPPORT AND SPONSORSHIP
sample size, even to compare, with multicentric
None.
randomized clinical trials, this novel approach with
the other conventional maxillary expansion protocol ETHICAL APPROVAL AND CONSENT TO PARTICIPATE
in patients with UCLP.
Research was performed in accordance with the Declaration of
5. CONCLUSION Helsinki and approved by the ethics committee of the University
of Campania Luigi Vanvitelli, Naples, Italy (Prot. N° 147).
An informed consent to participate in the study was obtained.
Growing patients with UCLP showed significant
differences in all transverse upper arch dimensions CONSENT FOR PUBLICATION
after orthodontic treatment with a bonded maxillary
expander and a hybrid activation protocol. A written informed consent for publication was obtained.
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Fabrizia D’APUZZO
DDS, MS, PhD, Research Fellow
Multidisciplinary Department of Medical-Surgical and Dental Specialties
University of Campania Luigi Vanvitelli Naples
Naples, Italy
CV
Fabrizia d’Apuzzo is a graduate of Dental Medicine (October 2012 with honors) from the Second University of Naples (Italy). She
attended the “Université Lille II Droit et Santé" in Lille (France) between September 2010 and April 2011 as an “Erasmus” student,
and the University of Trieste (Italy) on a 3-month travel grant from December 2011 to perform her experimental thesis. She was
awarded her Postgraduate Diploma in Orthodontics in February 2017 and her PhD in Biomedical and Biotechnological Sciences
in December 2019. And she is currently a Research Fellow at the University of Campania Luigi Vanvitelli, Naples (Italy).
Dr. d’Apuzzo has authored and co-authored more about 30 articles, 3 book chapters and over 40 posters. She has been a speaker
at international conferences and she received several awards and distinctions.
Stoma Edu J. 2020;7(3): 184-190 pISSN 2360-2406; eISSN 2502-0285 189
d’Apuzzo F, et al.
www.stomaeduj.com
Questions
Original Articles
1. Cleft lip and palate is a?
qa. Congenital craniofacial birth anomaly;
qb. Congenital dental disorder;
qc. Nosocomial infection;
qd. Acquired disorder.
2. What is the etiology of cleft lip and palate?
qa. Environmental;
qb. Genetic;
qc. Epigenetic;
qd. All of the aforementioned.
3. What is the first surgery performed in CLP patients?
qa. Alveolar bone graft;
qb. Lip;
qc. Soft palate;
qd. Hard palate.
4. Patients with cleft lip and palate can have
qa. Skeletal maxillary constriction;
qb. Dental posterior crossbite;
qc. Reduced intercanine widths;
qd. All of the aforementioned.
190 Stoma Edu J. 2020;7(3): 184-190 pISSN 2360-2406; eISSN 2502-0285