#4 Clinical Cases
CLP MAXILLARY MORPHOLOGY: A 3D EVALUATION outline
#1 Literature Review
#2 3D EvaluaDon Approach
#3 Maxillary Morphology Comparison: CleK vs Non-‐CleK Subjects
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Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate.
The Lancet 2009;374(9703):1773-85.
CLP is a craniofacial malformaDon due to the failure of fusion
of the maxillary processes and/or palatal shelves 4th -‐ 12th week of embryogenesis
CLP : 3D MAXILLARY MORPHOLOGY CHANGES definiDon and Dming
First-‐trimester diagnosis of cleK lip and palate using three-‐dimensional ultrasound. MarDnez-‐Ten P, Adiego B, Illescas T, Bermejo C, Wong AE, Sepulveda W. Ultrasound Obstet Gynecol. 2012 Jul;40(1):40-‐6. doi: 10.1002/uog.10139
Mossey et al, 2009 MarDnez-‐Ten et al, 2012 www.ortodonzia.unina2.it
CLP reflects the complexity and diversity of the mechanisms involved at molecular level during embryogenesis
Johnson MC, Bronsky PT. Prenatal craniofacial development: new insights on normal
and abnormal mechanisms. Critical Reviews in Oral Biology and Medicine 1995;6:25-79.
Schutte BC, Murray JC. The many faces and factors of oro-facial clefts.
Human Molecular Genetics 1999;8:1853-9.
Prescott NJ, Winter RM, Malcom S. Non-syndromic cleft lip and palate: complex
genetics and environmental effects. Annals of Human Genetics 2001;65:505-15.
Spritz RA. The genetics and epigenetics of oro-facial clefts.
Current Opinion in Pediatrics 2001;13:556-60.
Wilkie AO, Morriss Kay GM. Genetics of craniofacial development and
malformation. Nature Reviews Genetics 2001;2:458-68.
Murray J. Gene/environment causes of cleft lip and/or palate.
Clinical Genetics 2002;61:248-26.
Hayes, 2002 Murray, 2002
Czeizel and Bànhidy, 2010
CLP : 3D MAXILLARY MORPHOLOGY CHANGES eDology
Czeizel AE and Nagy E; 1986 Johnson MC and Bronsky PT; 1995 SchuEe BC and Murray JC; 1999
PrecooE NJ et al; 2001 Spritz RA; 2001
Wilkie AO and Morriss Kay GM; 2001
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geneDc and environmental factors oKen act in associaDon
CLP : 3D MAXILLARY MORPHOLOGY CHANGES eDology
Hayes, 2002 Murray, 2002
Czeizel and Bànhidy, 2010 Bezerra et al, 2014
MTHFR 677T allele Kim et al, 2009; Platek et al, 2009; Ho et al, 2013
Jianyan et al, 2010; Dixon et al, 2011; Ho et al, 2013; Kim et al, 2013
(Blanton et al, 2011) Platek et al, 2009; Bhaskar et al, 2011; Liang et al, 2014
Folic acid deficiency
MTHFR 677T allele < folic acid Alcohol consumpDon > MTHFR 1298C allele Alcohol consumpDon < folic acid
Alcohol consumpDon MTHFR 1298C allele
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1. CLEFT OF PRIMARY PALATE (lip -‐ alveolus)
2. CLEFT OF PRIMARY AND SECONDARY PALATE (lip -‐ alveolus -‐ hard -‐ soK palate)
CLP : 3D MAXILLARY MORPHOLOGY CHANGES classificaDon
ICPR, 2006
3. CLEFT OF THE SECONDARY PALATE (hard -‐ soK)
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CLP : 3D MAXILLARY MORPHOLOGY CHANGES epidemiology
CleK is the most common craniofacial malformaDon that an orthodonDst will encounter
Kawakami et al, 2002
incidence
Mossey and CasDllia, 2003 Bernheim et al, 2006
Thornton J.B, Nimer S, Howard P, 1996.
The Incidence, Classi>ication, Etiology and Embriology of Oral Cleft.
Seminar in Orthodontics; Sept; 2(3): 162-‐168.
Rodrigeuz C, Mosquera C, Garcia E, Fernandez J, Rodriguez A, Riano I, Ariza F. 2009.
The epidemiology of cleft lip and palate over the period 1990-‐2004 in Asturias.
An Pediatr (Barc) Aug 31.
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1/1000 1/700
Thornton J.B, Nimer S, Howard P, 1996.
The Incidence, Classi>ication, Etiology and Embriology of Oral Cleft.
Seminar in Orthodontics; Sept; 2(3): 162-‐168.
Rodrigeuz C, Mosquera C, Garcia E, Fernandez J, Rodriguez A, Riano I, Ariza F. 2009.
The epidemiology of cleft lip and palate over the period 1990-‐2004 in Asturias.
An Pediatr (Barc) Aug 31.
CleK palate 45.5%
CleK lip & palate 33%
CleK lip 21.5%
Rodriguez et al, 2009 Thornton et al, 1996 www.ortodonzia.unina2.it
prevalence
CLP : 3D MAXILLARY MORPHOLOGY CHANGES epidemiology
c
from birth unDl adulthood
Christensen et al, 2004 Okada et al, 2014
necessary to achieve a proper occlusion and beoer estheDcs
CLP : 3D MAXILLARY MORPHOLOGY CHANGES mulDdisciplinary approach
12. PlasDc Surgeon 13. Max-‐fac. Surgeon
14. AnestheDst 15. Radiologist
16. PedodonDst 17. OrthodonDst
12. PeriodonDst 18. Implantologist 19. ProsthodonDst
1. General PracDDoner
2. Gynecologist 3. Sonographer
4. Neonatologist 5. Pediatrician 6. GeneDcist 7. Psychologist 8. Social Worker 9. NutriDonist 10. Speech Therapist 11. Otorhinolaryngologist
Susumu TAKAYANAGI
piet haers
Maxillofacial Surgeon Gynecologist Sonographer Neonatologist Pediatrician GeneDcist Psychologist Social Worker NutriDonist Otorhinolaryngologist
Speech Therapist PlasDc Surgeon
General PracDDoner AnestheDst Radiologist PedodonDst OrthodonDst PeriodonDst
Implantologist ProsthodonDst
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…children without smiles are like a garden without flowers!
MARCO
CLP : 3D MAXILLARY MORPHOLOGY CHANGES orthodonDc treatment
CLP : 3D MAXILLARY MORPHOLOGY CHANGES problem list
DENTAL Ø Class II or III relaDonship Ø AgeneDc, rotated, anomalous
incisors
SKELETAL Ø Class II or III relaDonship Ø Hypo-‐hyperdivergent paoern
ESTHETIC Ø Convex or concave profile
FUNCTIONAL Ø Speech and/or oral breathing
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Anomalous upper arch and
palate morphology
COMMON DENOMINATOR
CLEFT LIP AND PALATE aim
CLP : 3D MAXILLARY MORPHOLOGY CHANGES aim
using 3D analysis to compare upper dental arch and palate morphology in untreated unilateral cleK vs untreated non-‐cleK
in mixed denDDon phase to examine arch width, palatal area and volume
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UCLP NCLP
ANNA CONTROL DIFFERENCE Values M ± SD Values %
ARCH WIDTH (mm)
Intercanine cusp 25 33.0 ± 2.3 -‐8 24.2%
Intercanine ging 20 25.5 ± 1.8 -‐5.5 21.5%
Intermolar cusp 46 48.0 ± 11.8 -‐2 4.1%
Intermolar ging 30 32.8 ± 8.2 -‐2.8 8.5%
PALATAL AREA (mm2)
753 776.9 ± 163.7 -‐23.9 3%
PALATAL VOLUME (mm3)
2694 2871.4 ± 898.7 -‐177.4 6.1%
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CLP : 3D MAXILLARY MORPHOLOGY CHANGES
Anna,
9 yrs and 11 mos
before…
Anna,
14 yrs and 1 mo
…aKer
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DIFFERENCE
Values %
ARCH WIDTH (mm)
Intercanine cusp 25 35 +10 39.3%
Intercanine ging 20 26 +6 30.2%
Intermolar cusp 46 54 +8 17.4%
Intermolar ging 30 36 +6 20.0%
PALATAL AREA (mm2) 753 992 +239 31.7%
PALATAL VOLUME (mm3) 2694 4563 +1869 69.3%
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before and aKer treatment
CLP : 3D MAXILLARY MORPHOLOGY CHANGES
Heoy, 11 yrs and 6 mos
1.2 2.2 2.3
3.7
Inter-‐disciplinary approach of a pa8ent with an unilateral cle; lip and palate Perillo L, Vitale M, d’Apuzzo F, Isola G, Nucera R, Matarese G
AJODO-‐D-‐16-‐0066R1
HETTY CONTROL DIFFERENCE
Values M ± SD Values %
ARCH WIDTH (mm)
Intercanine cusp 24 33.0 ± 2.3 -‐9 27.2%
Intercanine ging 18 25.5 ± 1.8 -‐7.5 29.4%
Intermolar cusp 46 48.0 ± 11.8 -‐2 4.1%
Intermolar ging 30 32.8 ± 8.2 -‐2.8 8.5%
PALATAL AREA (mm2) 700 776.9 ± 163.7 -‐76.9 9.8%
PALATAL VOLUME (mm3)
2586 2871.4 ± 898.7 -‐285.4 9.9%
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CLP : 3D MAXILLARY MORPHOLOGY CHANGES
Heoy,
11 yrs and 6 mos
before...
Heoy,
14 yrs and 6 mos
…aKer
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DIFFERENCE
Values %
ARCH WIDTH (mm)
Intercanine cusp 24 24 0 0%
Intercanine ging 18 18 0 0%
Intermolar cusp 46.5 49.5 +3 6.5%
Intermolar ging 30 33.5 +3.5 11.7%
PALATAL AREA (mm2)
700 700 0 0%
PALATAL VOLUME (mm3) 2586 3160 574 22.2%
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before and aKer treatment
CLP : 3D MAXILLARY MORPHOLOGY CHANGES
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Heoy, today