Tvar zubnõâho oblouku po uzaâ veï ru rozsïteï poveâ ho defektu posunem zubuê The shape of a dental arch after the closure of cleft space by movement of teeth MUDr. Helena KopovaÂ, MUDr. Magdalena Kot'ovaÂ, Ph.D. OddeÏ lenõâ ortodoncie a rozsïteï povyâch vad Stomatologicke kliniky 3. LF UK FNKV Praha Department of Orthodontics and Cleft Defects, Clinic of Stomatology, 3rd Medical Faculty of Charles University, University HospitalKra lovskeâ Vinohrady, Prague Souhrn UzavõÂra nõâ mezery v mõâsteï rozsï teï poveâ ho defektu posunem zubuê fixnõâm ortodontickyâ m aparaâ tem umozïnï uje funkcï nõâ a estetickou rehabilitaci chrupu bez nutnosti zhotovenõâ protetickeâ naâ hrady. Na 40 okluzogramech u 20 pacientuê s celkovyâ m jednostrannyâ m rozsï teï pem byl analyzovaâ n rozsah a charakter ortodontickyâ ch posunuê zubuê prïi uzaâveï ru rozsïteï poveâ ho defektu. Byl nalezen rozdõâlnyâ charakter zmeï n v postavenõâ a pohybech zubuê ve velkeâ m rozsïteï poveâ m segmentu cï elisti u pravostranneâ ho a levostranneâ ho celkoveâ ho rozsïteï pu, ke kteryâ m dosïloprïi uzavõâraâ nõâ rozsï teï poveâ ho defektu chrupu a uâ praveï tvaru hornõâho zubnõâho oblouku fixnõâm ortodontickyâ m aparaâ tem (Ortodoncie 2011, 20, cï. 2, s. 80-86). Abstract The space closure in the cleft region by means of tooth movement with fixed orthodontic appliance allows for a functional and aesthetic reconstruction of the dentition without prosthetic treatment. We made the analysis of 40 occlusograms of 20 patients with a complete unilateral cleft and evaluated the extent and characteristics of orthodontic tooth movements during the space closure in the cleft region. We found differences in position and movement of teeth in the large cleft segment for left-sided and right-sided complete cleft during the closure of the cleft space and adjustment of the arch shape of the upper arch with fixed orthodontic appliance (Ortodoncie 2011, 20, No. 2, p. 80-86). KlõÂcÏ ovaâ slova: celkovyâ jednostrannyâ rozsïteï p, fixnõâ aparaâ t, ortodontickyâ uzaâveï r defektu chrupu, zmeï ny postavenõâ zubuê Key words: complete unilateral cleft, fixed orthodontic appliance, orthodontic closure of the space in dentition, changes in the teeth position U vod RozsÏ teï py v orofaciaâ lnõâ oblasti jsou jednou z nejcï a- steï jsï õâch vrozenyâch vyâ vojovyâ ch vad. V CÏ eskeâ republice je dlouhodobaâ incidence vyâ skytu 1,8-2 na 1000 zï iveï narozenyâch deï tõâ [1, 2, 3]. Charakter defektu maâ teïzïkeâ negativnõâ duê sledky na polykaâ nõâ, dyâ chaâ nõâ, kousaâ nõâ, a tvorbu rïecï i. U 20% postizïenyâch je rozsïteï p kombinovaâ n s dalsï õâ zdravotnõâ zaâteïzïõâ [4, 5]. Plna rehabilitace Introduction Clefts in orofacial area belong amongst the most frequent congenital developmental anomalies. In the Czech Republic, the long-term incidence is 1.8-2.0 in 1.000 live births [1, 2, 3]. The defect seriously affects swallowing, breathing, biting as well as speech. In 20% of the affected children the cleft is accompanied by another health problem [4, 5]. Full rehabilitation of 80
rocïnõâk20 Methods In each plaster model - prior to the commencement of the orthodontic treatment with fixed appliance and after the appliance was removed - 10 points were marked on the outer curve of the dentalarch perimeter, mesially off both first permanent maxillary molars: tips of buccal cusps of maxillary premolars, tips of maxillary canines, and centres of cutting edges of maxillary incisors (Fig. 1). Results of individual measurements performed in models of dentition, in photographs of the models, and in occlusograms were compared. Multiple measuteï chto pacientuê vyzï aduje dlouhotrvajõâcõâ naâ rocï nou multidisciplinaâ rnõâ leâ cï bu [6]. U plneï odstranit vadu soucï asnaâ leâ karïskaâ veï da nedokaâ zï e [7]. ProtozÏ e sekundaâ rnõâ deformity a vadnyâ mluvenyâ projev mohou vyâ znamneï prïispõâvat ke snõâzïenõâ kvality zïivota jinak zcela zdraveâ ho jedince, je leâcï ba zameïrïena na minimalizaci nedostatkuê vzhledu a funkce postizï enyâ ch struktur[8]. KonecÏ naâ uâ prava chrupu fixnõâm ortodontickyâ m aparaâ tem by meï la byâ t u pacientuê s rozsï teï pem samozrïejmostõâ. Idea lnõâ variantou je uzaâ veï r rozsï teï poveâ ho defektu chrupu posunem zubuê bez nutnosti protetickeâ rekonstrukce. Dany stav je trïeba udrzï et stabilneï co nejdeâ le [9, 10]. Autorky povazï ujõâ analyâ zu zmeï n postavenõâ zubuê v pruêbeï hu ortodontickeâ leâcï by za velice duêlezïityâ faktor ovlivnï ujõâcõâ stabilitu vyâ sledku leâ cï by fixnõâm aparaâ tem. CõÂlem prïedklaâ daneâ praâ ce je proto analyâza zmeï n v postavenõâ jednotlivyâch zubuê po uzaâveï ru rozsïteï poveâ ho defektu chrupu posunem zubuê fixnõâm ortodontickyâm aparaâ tem u pacientuê s celkovyâ m jednostrannyâ m rozsïteï pem hornõâ cï elisti. MateriaÂl Bylo analyzovaâ no 40 okluzogramuê saâ drovyâ ch modeluê chrupu 20 pacientuê s celkovyâ m jednostrannyâ m rozsï teï pem hornõâ cï elisti prïed a po uâ praveï tvaru hornõâho zubnõâho oblouku fixnõâm aparaâ tem ve smyslu uzaâ veï ru rozsï teï poveâ ho defektu chrupu posunem zubuê. 12 pacientuê meï lo celkovyâ levostrannyâ rozsïteï p a 8 pacientuê meï lo celkovyâ pravostrannyâ rozsïteï p hornõâ cï elisti, 14 pacientuê byli muzïi a 6 pacientuê byly zïeny. VsÏ ichni pacienti byli ortodonticky leâcï eni podle stejneâholeâcï ebneâ ho protokolu na OddeÏ lenõâ ortodoncie a rozsïteï povyâch vad Stomatologicke kliniky FNKV Praha. PruÊ meï rnaâ doba leâcï by fixnõâm aparaâ tem byla 3 roky, vcï etneï kladenõâ duê razu na dostatecï nou retencï nõâ faâ zi ortodontickeâ terapie staâ vajõâcõâm fixnõâm aparaâ tem, kteryâ uzï nebyldaâ le aktivovaân. Metodika Na kazïdeâm saâ droveâ m modelu prïed zahaâ jenõâ ortodontickeâ l eâ cï by fixnõâm aparaâ tem a po sejmutõâ fixnõâho aparaâ tu bylo vyznacï eno 10 sledovanyâch boduê na zevnõâ krïivce perimetru zubnõâho oblouku meziaâlneï od obou prvnõâch staâlyâch hornõâch molaâruê. Byly to tyto body: vrcholy bukaâ lnõâch hrbolkuê hornõâch premolaâ ruê, hroty hornõâch sï picï aâkuê a strïedy rïezacõâch hran hornõâch rïezaâkuê (obr. 1). Byly porovnaâ ny vyâ sledky jednotlivyâ ch meï rïenõâ na saâ drovyâ ch modelech chrupu, na fotografiõâch saâ dro- Obr. 1: Okluzogram s vyznacï enyâmi body Fig. 1: Occlusogram with points marked those patients requires a long-time and demanding multidisciplinary treatment [6]. Currently, the medical science is not able to eliminate the anomaly completely [7]. As the secondary deformities and defective speech significantly contribute to the lower quality of life of an otherwise healthy individual, the treatment focuses to minimize the defects in appearance and functions of structures affected by the anomaly [8]. Final adjustment of the dentition with fixed orthodontic appliance should become the golden rule in patients with cleft. The ideal solution is the closure of the cleft defect of the dentition without prosthetic reconstruction, and stabilization of the condition for as long as possible [9, 10]. The authors of this study consider the analysis of changes in the position of teeth during the orthodontic treatment a very important factor affecting the stability of the treatment result with fixed appliance. The aim of the work is, therefore, the analysis of changes in the position of individual teeth after the closure of the cleft space with fixed orthodontic appliance in patients with a complete unilateral cleft of the upper jaw. Material We performed the analysis of 40 occlusograms of models of the dentition of 20 patients with a complete unilateral cleft of the upper jaw prior to and after the adjustment of the upper dentalarch shape with fixed orthodontic appliance that facilitated the closure of the cleft space by means of the tooth movement. 12 patients had a complete unilateral cleft on the left, 8 patients a complete unilateral cleft on the right side of the upper jaw; there were 14 male and 6 female patients. All the patients underwent orthodontic treatment according to the same treatment protocolat the Department of Orthodontics and Cleft Defects, Clinic of Stomatology, 3rd Medical Faculty of Charles University, University HospitalKra lovskeâ Vinohrady, Prague. The mean length of the treatment with fixed orthodontic appliance was 3 years, including the retention phase with the current fixed appliance that was not further activated. 81
vyâ ch modeluê a na okluzogramech. VõÂcecÏ etnyâ m meï rïenõâm bylo zjisï teï no, zï e nejprïesneï jsï õâ vyâ sledky byly opakovaneï zmeï rïeny na okluzogramech, ktereâ byly proto zvoleny jako nejvhodneïjsï õâ pro definitivnõâ meïrïenõâ. Na okluzogramech byly stanoveny na milimetroveâ sõâti osy x a y, na nichzï jsme vyjaâdrïili zmeï ny v postavenõâ zubuê v rozsahu 5+ azï +5 ve smeï ru anteroposteriornõâm (osa y) a transverzaâlneï (osa x). Osa x byla urcï ena jako prïõâmka puê lõâcõâ uâ hel mezi liniõâ spojujõâcõâ body lezï õâcõâ nejdistaâlneï ji na obvodu klinickeâ korunky zubuê 6+6 a mezi liniõâ spojujõâcõâ body lezï õâcõâ nejmeziaâ lneï ji na obvodu klinickeâ korunky 6+6 (Obr. 2). U pacientuê s levostrannyâm rozsïteï pem osa y tvorïõâ tecï nu k bodu lezïõâcõâmu nejlateraâlneï ji na konvexiteï zubu 6+, u pravostranneâ ho rozsï teï pu v bodu umõâsteï neâ mu nejlateraâ lneï ji na konvexiteï zubu +6. Hodnocenõ dentaâ lnõâch zmeï n bylo provedeno na pruê svitneâ m papõârïe, na kteryâ byla pro prïesnyâ odecï et zkopõârovaâ na milimetrovaâ sõât'. Obr. 2: Konstrukce osy x Fig. 2: Construction of the x- axis Da le byl okluzogram s vyznacï enyâm krïõâzï em, kteryâ znaâ zornï uje osu x a y vlozï en pod pruê svitnyâ papõâr tak, aby se osy na milimetroveâ m papõârïe a na okluzogramu prïekryâ valy. Zvolene referencï nõâ body prïed leâ cï bou a po leâcïbeï byly prïeneseny na milimetrovyâ papõâr. NejdrÏõÂve byly na okluzogramu vyznacï eny body prïed leâcï bou. Pote bylmilimetrovyâ papõâr s jizï existujõâcõâm krïõâzï em podlozï en okluzogramem s osami x a y, ale tentokraâ t s referencïnõâmi body zaznamenanyâmipoleâcï beï. Body znacïeneâ pol eâcïbeï byly odlisï eny od boduê prïed leâcï bou jinou barvou (Obr. 3). Pro kazïdyâ zub byly odecï teny zmeï ny na ose x (transverzaâ lnõâ smeï r) a na ose y (anteroposteriornõâ smeï r). Na ose x (transverzaâlneï ) v celeâ m souboru kladneâ znameâ nko vzï dy znamenalo posun ¹k patroveâ mu sï vuª azaâ porneâ znameâ nko vzï dy posun ¹od patroveâhosï vuª. Na ose y (anteroposteriorneï ), pokud dosï lo k posunu zubu smeï rem anteriornõâm, oznacï ujeme vyâ sledek v kladnyâch hodnotaâ ch a naopak, pokud dosï lo k posunu zubu smeï rem posteriornõâm, vyjadrïujeme vyâ sledek v zaâ pornyâ ch hodnotaâ ch. VesÏ kereâ zõâskaneâ uâ daje byly zpracovaâ ny programem SPSS verze 15, SPSS Inc. Chicago, USA. Vy sledky 1. Pacienti s celkovyâm levostrannyâm rozsïteï pem. JednovyÂbeÏ rovyâmi t-testy bylo prokaâzaâ no, zïe k patroveâmu sï vu se posunuly 3+, 2+ a 1+, od patroveâho sï vu se posunuly +1, +3, +4 a +5. PosteriorneÏ se posunulzub +1, anteriorneï se posunuly +3, +4 a +5. U ostat- rements showed that the most accurate results were obtained in occlusograms. They were, therefore, chosen as the best for the finalmeasurement. In occlusograms - in a milimeter grid - axes x and y were determined. Changes in position of teeth from 5+ to +5 in anteroposterior direction (axis y) and in transversaldirection (axis x) were recorded. Axis x was determined as the straight line bisecting the angle between the line connecting the most distal points on the clinical crowns of teeth 6+6, and the line connecting the most mesialpoints on the clinicalcrown 6+6 (Fig.2). In patients with clefts on the left side, y- axis forms a tangent to the point located most laterally on the tooth 6+ convexity, in patients with the cleft on the right side it is in the point located most laterally on the tooth +6 convexity. Changes in position of teeth were evaluated on the transparent paper with millimeter grid. The occlusogram with the cross representing axes x and y was inserted under the transparent paper in such a way that the axes on millimeter paper and on occlusogram coincided. Reference points prior to and after the therapy were transferred onto the millimeter grid. First, the points prior to the therapy were marked in the occlusogram. Then the occlusogram with axes x and y and reference points marked after the treatment was inserted under the millimeter paper. Points after the treatment were marked with different colour than the points referring to the situation prior to treatment (Fig. 3). For each tooth the changes were read on x - axis (transversaldirection), and on y - axis (anteroposterior direction). Obr. 3: ReferencÏ nõâ body na milimetroveâ m papõâru. ModrÏe - stav prïed leâcï bou acï erveneï - po leâcïbeï. Fig. 3: Reference points in the millimeter paper grid. Blue - situation prior to treatment, red - situation after treatment On x - axis (transversally) in the whole sample the positive sign always meant movement ¹to palatal sutureª, and the negative sign always meant movement ¹off palatal sutureª. On y - axis (anteroposteriorly), the positive sign meant movement of the tooth in anterior direction, and the negative sign meant movement in posterior direction. All the data thus obtained were processed with the software SPSS, version 15, SPSS Inc. Chicago, USA. Results 1. Patients with a complete unilateral cleft left side Unpaired t-tests proved that 3+, 2+ and 1+ moved toward palatal suture, while +1, +3, +4, and +5 moved off the palatal suture. +1 moved in posterior direction, +3, +4, and +5 moved in anterior direction. In other teeth 82
rocïnõâk20 Tabulka 1: Posuny zubuê u levostranneâ ho a pravostranneâ ho rozsïteï pu v ose x a y Table 1: Movements of teeth in left-side and right-side clefts in the axes x and y 5+ 4+ 3+ 2+ 1+ +1 +2 +3 +4 +5 N 12 10 11 9 12 12 2 12 11 12 Left cleft Mean -1.29 1.35 3.09*** 3.61*** 2.50** -1.96* 1.25-3.83* -3.05*** -2.96* SD 2.15 2.21 2.14 1.90 2.15 2.40 6.01 4.58 2.32 4.22 x-axis Min. -6.0-3.5.0 1.5 -.5-7.0-3.0-11.0-6.5-9.0 Max. 2.0 3.5 6.5 7.5 7.5 1.5 5.5 5.0 1.0 5.5 N 12 10 11 9 12 12 2 12 11 12 Left cleft Mean.79 -.05-1.05 -.78 -.79-1.38* 4.0 3.08** 1.8* 1.63* SD 1.51 1.40 2.06 1.70 2.06 1.98 2.83 3.19 2.37 2.01 y-axis Min. -.5-2.0-5.0-3.5-5.0-4.5 2.0-2.0-3.0-1.5 Max. 5.0 2.0 3.0 1.5 2.0 2.0 6.0 8.0 5.5 5.0 N 8 7 8 1 8 8 7 8 4 8 Right cleft Mean -1.0-1.57* -1.19.0.06.75 -.57 -.25-2.13* -1.81** SD 2.27 1.54 1.55. 2.29 2.39 2.28 1.46 1.18 1.03 x-axis Min. -3.5-3.5-3.5.0-3.0-3.5-4.0-3.0-3.0-3.5 Max. 3.0 1.0 1.0.0 4.5 4.0 3.0 1.5 -.5 -.5 N 8 7 8 1 8 8 7 8 4 8 Right cleft Mean.25.50 1.31 1.0 -.75 -.44.93 -.13 -.13.31 SD.85 1.04 1.68. 1.10 1.21 1.43 1.75 2.02 1.33 y-axis Min. -.5-1.0.0 1.0-2.5-2.5-1.5-3.5-2.5-1.5 Max. 1.5 2.0 4.5 1.0 1.0 1.0 3.0 2.0 2.0 2.0 N počet pacientů, number of patiens, Mean aritmetický průměr, SD směrodatná odchylka, standard deviation, Min. minimální hodnota, minimal value, Max. maximální hodnota, maximal value. Statisticky potvrzené rozdíly, statistically significant differences: *p<0.05, **p<0.01, ***p<0.001. Obr. 4: Posuny zubuê poleâcïbeï fixnõâm aparaâ tem u celkoveâ ho levostranneâ ho rozsï teï pu. Statisticky vyâznamneâ zmeï ny jsou znaâ zorneï ny cï erveneï. Fig. 4: Movement of teeth after treatment with fixed appliance in patients with a complete unilateral cleft on the left. Statistically significant changes are in red. nõâch zubuê nedosï lo k statisticky vyâ znamneâ mu posunu na uâ rovni p < 0,05 (Tabulka 1, Obr. 4). 2. Pacienti s celkovyâm pravostrannyâm rozsïteï pem JednovyÂbeÏ rovyâmi t-testy bylo prokaâzaâ no, zïe od patroveâhosï vu se posunuly 4+, +4 a +5. U ostatnõâch zubuê nedosï lo k statisticky vyâznamneâ mu posunu na uâ rovni p < 0,05 (Tabulka 1, Obr. 5). Obr. 5: Posuny zubuê poleâcïbeï fixnõâm aparaâ tem u celkoveâ ho pravostranneâ ho rozsï teï pu. Statisticky vyâ znamneâ zmeï ny a smeï r pohybuê jsou znaâ zorneï ny cï erveneï. Fig. 5: Movement of teeth after treatment with fixed appliance in patients with a complete unilateral cleft on the right. Statistically significant changes are in red. there was found no statistically significant movement (the level of significance p < 0.05 (Table 1, Fig. 4). 2. Patients with a complete unilateral cleft the right side Unpaired t-tests proved that 4+, +4, and +5 moved off the palatal suture. In other teeth there was found no statistically significant change (the level of significance p < 0.05 (Table 1, Fig. 5). 83
Diskuse Te matem prïedklaâ daneâ praâ ce bylo popsat morfologickeâ zmeï ny zubnõâho oblouku, prïesneï jizmeï ny v postavenõâ jednotlivyâ ch zubuê hornõâ cï elisti u pacienta s celkovyâm jednostrannyâm rozsïteï pem po leâcïbeï fixnõâm aparaâtem. Za rovenï jsme porovnali zmeï ny v postavenõâ zubuê v maleâ m a velkeâ m segmentu hornõâ cï elisti po leâcïbeï mezi skupinami pacientuê s celkovyâ m levostrannyâ m a pravostrannyâm rozsïteï pem. A to proto, zï e v odborneâ literaturïe jsou uâ daje, ktereâ popisujõâ tvar zubnõâho oblouku u pacienta s rozsïteï pem, spõâsï e zameïrïeny na celkovyâ vztah hornõâho a dolnõâho zubnõâho oblouku, nebo vztah jednotlivyâ ch zubuê, cozï vyjadrïujõâ naprïõâklad Goslon Yardstick nebo Huddart Bodenham skoâ re [11, 12, 13]. NaÂsÏ soubor pacientuê tvorïili pacienti s teï zï kyâ m typem rozsï teïpoveâ ho defektu, avsï ak pro uâ pravu tvaru zubnõâho oblouku byla pouzï ita pouze ortodontickaâ terapie bez vyuzï itõâ protetickeâ rekonstrukce nebo dentaâ lnõâ implantologie. Za rovenï jsme hledali takovyâ soubor, kde pacienti byli operovaâniprïiblizïneï ve stejneâmveï ku podle stejneâ ho chirurgickeâ ho protokolu a to z toho duê vodu, zï e morfologie rozsïteï poveâ cï elisti je znacïneï determinovaâ na chirurgickyâ mi intervencemi [14, 15]. ChteÏ li jsme veï deï t, jak velkeâ a jakeâ ortodontickeâ posuny bylo trïeba pro uzaâ veï r rozsï teï poveâ ho defektu pouze ortodontickyâm posunem zubuê, cozï je pro pacienta nejmeâneï invazivnõâ a nejmeâ neï zateï zï ujõâcõâ rïesï enõâ. Proteticke rïesï enõâ, i kdyzï je vyhovujõâcõâ, maâ cï asoveï omezenou trvanlivost a s preparacõâ pilõârïovyâ ch zubuê se biologickyâ faktor chrupu jizï u velmi mladyâ ch jedincuê vyâ znamneï snizï uje[16]. Rezervy pro dalsï õâ rïesï enõâ po uplynutõâ doby funkcï nõâ a estetickeâ zï ivotnosti protetickeâ praâ ce jsou diskutabilnõâ[17]. RovneÏ zï rekonstrukce rozsï teï poveâ ho defektu dentice dentaâ lnõâm implantaâ tem nenõâ ani u nerozsïteï poveâ ho pacienta dozïivotnõâ a musõâme si rovneïzï poklaâ dat otaâ zku, jak budeme postupovat v terapii daâle, pokud invazivneï jsï õâ postupy indikujeme u mladyâ ch pacientuê jako prvnõâ rïesï enõâ [18]. UzaÂveÏ r rozsïteï poveâ ho defektu chrupu postupnou mezializacõâ lateraâlnõâho uâ seku je, dle rïady autoruê, nejvhodneï jsï õâm zpuê sobem rekonstrukce zubnõâho oblouku. PatrÏõ vsï ak k nejnaâ rocï neï jsï õâm a vyzï aduje urcï iteâ modifikace leâ cï ebneâ ho protokolu. U celkoveâ ho jednostranneâ ho rozsï teï pu hornõâ cï elisti nachaâ zõâme obdobnyâ typ ortodontickyâ ch posunuê a obdobnou morfologickou odpoveïd'na leâcï bu jednak ve frontaâ lnõâm uâ seku zubnõâho oblouku a daâ le v oblasti u sï picï aâ ku a premolaâ ruê maleâ ho segmentu. Uvedene zuby maleâ ho segmentu se pohybujõâ anteriorneï a vestibulaâ rneï. Anteriornõ cï aâ st chrupu velkeâ ho segmentu se oplosï t'uje, zuby se pohybujõâ smeï rem oraâ lnõâm. Jako nejcï asteï ji nespraâ vneï postaveneâ zuby hodnotõâme premolaâ ry velkeâ ho segmentu. U celkoveâ ho jednostranneâ ho rozsï teï pu hornõâ cï elisti se lisï õâ mõâra a typ zmeï n v postavenõâ zubuê poleâcïbeï u pra- Discussion The aim of the work presented was to describe morphological changes of dental arch; more precisely, the changes in the position of individualteeth in the upper arch in the patient with a complete unilateral cleft after treatment with fixed orthodontic appliance. At the same time we also compared the changes in the position of teeth in a small segment and a big segment of the upper jaw after the treatment - between the groups of patients with unilateral cleft on the left side and on the right side. The literature focuses rather on the overall relationship between the upper and lower dental arches, or on the relationship between individual teeth, e.g. Goslon Yardstick and Huddart Bodenham score [11, 12, 13]. Our sample of patients included patients with a severe type of the cleft defect. However, for the adjustment of the dentalarch shape only orthodontic therapy was applied, without prosthetic reconstruction or dental implants. At the same time we also wanted to work with the sample including patients who were operated at approximately the same age and according to the same surgery protocol- because the morphology of the cleft jaw is significantly determined by surgicalinterventions [14, 15]. We wanted to identify how extensive and what orthodontic movements were required for the closure of the cleft defect through the orthodontic teeth movement, which is the least invasive approach and the most comfortable method for a patient. The prosthetic treatment - though it is suitable - is limited in terms of duration, and the preparation of the pillar teeth significantly decreases the biological factor of the dentition already in very young individuals [16]. Further management of the defect, after the prosthetic solution, is still the subject of a lively debate [17]. The reconstruction of the cleft defect with a dental implant is not life-long, and again we have to consider the future therapy - what approach to use if we indicate invasive methods as the methods of first choice even in very young patients? [18] A number of authors agree that the closure of the cleft defect by gradual mesialisation of the lateral segment is the best method for the dentalarch restoration. Nevertheless, it is a very demanding technique which requires some modifications of treatment protocol. In a complete unilateral maxillary cleft we can find similar type of orthodontic movements and similar morphological response to the treatment in the anterior segment of the dentalarch, and further in canine and premolars of the small segment. The teeth of the small segment move anteriorly and vestibularly. The anterior part of the teeth of the big segment flattens, the teeth move in oraldirection. Premolars in the big segment are usually the teeth with incorrect position. 84
rocïnõâk20 vostranneâ ho a levostranneâ ho typu defektu ve velkeâ m segmentu. To je skutecï nost, kteraâ naâ s zaujala, zatõâm pro ni nemaâ me vysveï tlenõâ a jeho hledaâ nõâ bude vyzï adovat prïedevsï õâm zpracovaânõâveïtsï õâch souboruê pacientuê. U obou typuê rozsïteï pusemeï nõâ postavenõâ zubuê frontaâlnõâho uâ seku chrupu, kteryâ tvorïõâ zuby prïednõâho poâ lu velkeâ ho segmentu. U levostranneâ ho rozsï teï pu se vsï echny zuby anteriornõâho poâ lu velkeâ ho segmentu posunujõâ oraâ lneï a smeï rem k rozsï teï poveâ mu defektu. Chceme-li dosaâ hnout uzaâ veï ru mezery u pravostranneâ ho rozsïteï pu, pohybujõâ se zuby frontaâlnõâho uâ seku prïekvapiveï smeï rem od rozsï teï poveâ ho defektu. PotrÏeba oraâ lnõâho sklonu cï i posunu je opeï t stejnaâ, jako u levostranneâ ho rozsïteï pu. Tato skutecï nost muêzïe byât duêlezï itaâ prïi realizaci pozï adavkuê chirurga na rozmeï ry rozsïteï poveâ ho defektu prïed rekonstrukcõâ alveolaâ rnõâho vyâbeï zï ku spongioâ znõâ kostõâ (tzv. spongioplastikou). Znamena to totizï, zï e u pravostranneâ ho rozsïteï pu nenõâ vhodneâ (pokud nenõâ prïõâtomen obraâ cenyâ skus plaâ novanyâ k ortodontickeâ korekci) prïi uâ praveï mezery prïed doplneï nõâm kosti otevõârat rozsïteï povyâ defekt protruzõâ rïezaâ kuê, chceme-li naâ sledneï rozsï teï povyâ defekt chrupu uzavrïõât posunem zubuê. PrÏi spongioplastice by tudõâzï meï lbyâ t jasnyâ dalsï õâ terapeutickyâ pl aâ n.v prïõâpadeï meziaâ lnõâch posunuê by se mezera meï la prïedevsï õâm upravovat pohybem lateraâ lnõâch zubuê maleâ ho segmentu smeïrem vestibulaâ rnõâm. NavõÂc prïitom musõâme respektovat mõâsto pro sï picïaâ k. NasÏ e soubory jsou velmi maleâ na to, abychom nalezeneâ skutecï nosti mohli zobecnï ovat. ZõÂskane vyâ sledky je trïeba oveï rïit, protozï e mohou naznacï ovat i poneï kud jinou morfologii zubnõâho oblouku (a tedy mõâry nutnyâch terapeutickyâch zmeï n v postavenõâ zubuê ) u obou typuê celkovyâch rozsïteïpuê a nebo, zï e u pravostranneâ ho rozsï teï pu nenõâ rozsï teï povaâ deformace tvaru zubnõâho oblouku tak vyâ raznaâ. Tvar zubnõâho oblouku a interkuspidace jsou duê lezï iteâ pro stabilitu vyâsledku ortodontickeâ l eâ cï by. U pacienta s celkovyâ m rozsï teï pem ovsï em musõâme dlouhodobeï stabilizovat nejen postavenõâ zubuê po l eâcï beï, ale i transverzaâ lnõâ rozmeï ry rekonstruovaneâ ho patra a braâ nit kolapsu lateraâ lnõâch uâ sekuê tahem jizvy. In a complete unilateral maxillary cleft the extension and types of changes in teeth positions after the treatment are different in the left-side and right-side defect in the big segment. The fact is very interesting, though so far we are not able to explain it - larger samples of patients are necessary for the analysis. In both types of the cleft, the position of teeth in the anterior segment is altered. In case of the left-side defect all teeth of the anterior pole of the big segment move orally and toward the cleft defect. In case of the right-side defect, the teeth of the frontalsegment move off the cleft defect. The oralinclination or movement is the same as in the case of the left-side defect. This fact may be important for surgeon requirements regarding the dimensions of the cleft defect prior to reconstruction of alveolar process with spongious bone (the so-called spongioplasty). In the cleft defect located on the right, it is not appropriate (unless there is a crossbite already indicated for an orthodontic correction) to open the cleft defect with incisors protrusion (when we modify the space before spongioplasty) in case we want to close the defect with teeth movement. Therefore, spongioplasty should be well planned and there should be prepared also the following treatment methods. When mesialmovements are employed, the space should be solved especially with the movement of lateral teeth of the small segment in vestibular direction. We have to take into account the location of the canine. Our samples of patients are too small for us to be able to make general conclusions. The results obtained must be reviewed because they may also imply a bit different morphology of the dental arch (and thus also necessary therapeutic alterations in teeth positions) in both types of a complete cleft, or that in case of the cleft located on the right the deformity of the dentalarch is less pronounced. The shape of the dentalarch and interdigitation of teeth are important factors of the stability of the orthodontic treatment results. In the patient with a complete cleft we have to stabilize not only the position of teeth after treatment, but also transversal dimensions of the reconstructed palate, and prevent the collapse of lateral segments due to scar pull. ZaÂveÏr CõÂlem praâ ce bylo zhodnotit typ a rozsah zmeï n v postavenõâ zubuê po l eâ cï beï fixnõâm aparaâ tem u pacienta s celkovyâ m jednostrannyâ m rozsï teï pem. I kdyzï je morfologie oblouku na konci leâcï by do znacï neâ mõâry determinovaâna chirurgickyâ mi intervencemi, nasï li jsme statisticky vyâznamneâ zmeï ny v postavenõâ zubuê po l eâ cï beï a prokaâ zali jsme urcï iteâ spolecïneâ znaky pro pohyby zubuê v maleâm segmentu rozsïteï poveâ cï elisti a ve frontaâ lnõâm uâ seku chrupu. ZmeÏ ny v postavenõâ zubuê ve velkeâ m segmentu rozsïteï poveâ cï elisti se vsï ak u levostranneâ ho a pravostranneâ ho rozsïteïpu lisï õâ. Pokud se tyto naâ lezy potvrdõâ Conclusion The aim of our study was to evaluate the type and extent of changes in position of teeth after treatment with fixed orthodontic appliance in patients with a complete unilateral cleft. Though the morphology of the dentalarch is - at the end of the treatment - considerably determined by surgical interventions, we found statistically significant changes in the position of teeth after treatment and we proved some common features for the movement of teeth in the big segment and in the anterior segment of dentition. However, the changes are different for clefts located on the left side and 85
na veï tsï õâch souborech pacientuê, mohly by prïispeï t k efektivneï jsï õâmu sestavenõâ plaânu leâcï by u jednotlivyâch typuê rozsïteïpuê. PodeÏ kovaâ nõâ: Autorky deï kujõâ Mgr. KaterÏineÏ Langove za vyâ znamnou pomoc prïi statistickeâ m zpracovaâ nõâ vyâsledkuê praâ ce. AutorÏi nemajõâ komercï nõâ, vlastnickeâ nebo financï nõâ zaâ jmy na produktech nebo spolecï nostech popsanyâ ch v tomto cïlaâ nku. those located on the right side. We believe that when the results will be proved in larger samples of patients, they may contribute to a more effective treatment plan for a specific type of the cleft defect. Acknowledgments: Authors would like to thank Mgr. KaterÏina LangovaÂ, Ph.D. for her selfless help in statistical processing of the data obtained. Authors have no commercial, proprietary or financial interest in products or companies mentioned in the article. Literatura/References 1. Peterka, M.: PrÏõÂcÏ iny vzniku vrozenyâch vad, jejich leâcïba a prevence. Praha: Akademie veïd CÏ eskeâ republiky, 2005. 2. Millard, D. R.; McNeill, K. A.: The incidence of cleft lip and palate in Jamaica. Cleft Palate J. 1965, 2, s. 384-388. 3. VanÏ kovaâ Z., Urbanova W., Kot'ova M.: Incidence rozsïteïpovyâch vad hornõâ cï elisti v cï eskeâ populaci v letech 2000-2006. Studentska veï deckaâ konference 2. LF UK, 7.-8. 4. 2010. 4. DusÏ kovaâ, M. a kol.: Pokroky v sekundaâ rnõâ leâcïbeï nemocnyâch s rozsïteï pem. Hradec Kra loveâ : Olga CÏ ermaâ kovaâ, 2007. 5. Gilmore, S. I.; Hofman, S. M.: Clefts in Wisconsin: Incidence and related factors. Cleft Palate J. 1966, 3, s. 186-199. 6. ZÏ izï ka, J.: Diagno za syndromuê a malformacõâ. Praha: Gale n, 1994. 7. Kot'ovaÂ, M.; Peterka, M.; Urban, F.; SÏ mahel, Z.: RozsÏteÏpy od A do Z. Odborny seminaârï pro obor ortodoncie. Praha, 2004. 8. TolarovaÂ, M.; Harris, J.: Reduced recurrence of orofacial clefts after periconceptional supplementation with highdose folic acid and multivitamins. Teratology. 1995, 51, cï. 2, s. 71-78. 9. UrbanovaÂ, W.: Ortodonticka prechirurgickaâ l eâ cï ba u pacienta s rozsï teï pem. Odborna atestacï nõâ praâ ce z oboru ortodoncie. Praha, 2007. 10. KleidienstovaÂ, Z.: Anoma lie v pocï tu zubuê u pacienta s rozsïteï pem. Odborna atestacï nõâ praâ ce z oboru ortodoncie. Praha, 2006. 11. Heidbuchel, K.L.; Kuijpers-Jagtman, A.M.: Maxillary and mandibular dental-arch dimensions and occlusion in bilateral cleft lip and palate patients form 3 to 17 years of age. Cleft Palate craniofac. J. 1997, 34, cï. 1, s. 21-26. 12. Shetye, P. R.; Evans, C. A.: Midfacial morphology in adult unoperated complete unilateral cleft lip and palate patients. Angle Orthodont. 2006, 76, cï. 5, s. 810-816. 13. Hermann, N. V.; Jensen, B. L.; Dahl, E.; Bolund, S.; Darvann, T. A.; Kreiborg, S.: Craniofacialgrowth in subjects with unilateral complete cleft lip and palate, and unilateral incomplete cleft lip, from 2 to 22 months of age. J. craniofac. genet. Dev. Biol. 1999, 19, cï. 3, s. 135-147 14. Diah, E.; Lo, L. J.; Huang, C. S.; Sudjatmiko, G.; Susanto, I.; Chen, Y. R.: Maxillary growth of adult patients with unoperated cleft: Answers to the debates. J. plast. reconstr. Aesthet. Surg. 2007, 60, cï. 4, s. 407-413. 15. Vora, J. M.; Joshi, M. R.: Mandibular growth in surgically repaired cleft lip and cleft palate individuals. Angle Orthodont. 1977, 47, cï. 4, s. 304-312. 16. SÏ mahel, Z.; MuÈ llerovaâ, Z.: RuÊst a vyâvoj oblicï eje u rozsï teï puê rtu a/nebo patra: I. Kraniofacia lnõâ odchylky, jejich prïõâcï iny a duê sledky. CÏ es. Stomat. 2000, 100, cï. 1, s. 9-16. 17. Hotz, M. M.; Gnoinski, W. M.: Effects of early maxillary orthopaedics in coordination with delayed surgery for cleft lip and palate. J. maxillofac. Surg. 1979, 7, cï. 3, s. 201-210. 18. Bardach, J.; Bakowska, J.; McDermott-Murray, J.; Mooney, M. P.; Dusdieker, L. B.: Lip pressure changes following lip repair in infants with unilateral clefts of the lip and palate. Plast. reconstr. Surg. 1984, 74, cï. 4, s. 476-481. MUDr. Helena Kopova Stomatologicka klinika FNKV Praha SÏ robaâ rova 50, 100 34 Praha 10 ROD a. s. porïaâdaâ 14. 10. 2011 PrÏednaÂsÏ ejõâcõâ: Dr. Aladin Sabbagh MõÂsto konaânõâ:praha Te ma: ¹Troubleshooting in Orthodontic Treatmentª Co deï lat kdyzï nastane probleâmprïi leâcïbeï?±prïednaâsï ka v anglicï tineï ROD a. s., Na Sa dce 780/20, 149 00 Praha 4, tel.: 224 314 806, fax: 233 323 670, e-mail: info@rodpraha.cz, www.rodpraha.cz 86