Original Article

Assessment of the alveolar bone support of patients

with unilateral cleft lip and palate:
A cone-beam computed tomography study
Esra Ercana; Mevlut Celikoglub; Suleyman Kutalmis Buyukc; Ahmet Ercan Sekercid

ABSTRACT
Objective: To assess the bone support of the teeth adjacent to a cleft using cone-beam computed
tomography (CBCT).
Materials and Methods: The CBCT scans of 31 patients with unilateral cleft lip and palate (UCLP)
were assessed. The data for teeth neighboring the cleft were compared with those of contralateral
noncleft teeth. For each tooth analyzed, the distance between the cementoenamel junction (CEJ)
and the bone crest (AC) at the buccal side was measured as was the thickness of the buccal bone
level at 0, 1, 2, and 4 mm.
Results: The bone thicknesses of the central teeth at the cleft region at the crest and 2 mm apically
were statistically significantly thinner than that of the central incisor at a noncleft region. The CEJ-
AC distance for central teeth at the cleft region was higher than that for central teeth in a noncleft
region.
Conclusions: Subjects with UCLP showed reduced bone support at teeth neighboring the cleft
compared with controls. This may cause some problems during orthodontic treatment. (Angle
Orthod. 0000;00:000000.)
KEY WORDS: Cleft lip and palate; Cone beam CT; Alveolar bone support

INTRODUCTION periodontitis and mucogingival problems3 for several

Complete cleft of the lip, alveolus, and/or palate
(CLAP) is the most common congenital malformation
of the face.1 Most affected children show a deficiency
in soft tissues and the alveolus and malformation of the
teeth at the cleft region. Problems are commonly seen
in feeding, speaking, and hearing; many esthetic,
dental, and psychological problems may also be
encountered.2 Additionally, children and youths with
CLAP are at increased risk for the development of
a
Assistant Professor, Department of Periodontology, Karade-
niz Technical University, Trabzon, Turkey.
b
Associate Professor, Department of Orthodontics, Akdeniz
University, Antalya, Turkey.
c
Research Assistant, Department of Orthodontics, Ordu
University, Ordu, Turkey.
d
Assistant Professor, Department of Oral and Maxillofacial
Radiology, Erciyes University, Kayseri, Turkey.
Corresponding author: Dr Esra Ercan, Karadeniz Technical
University, Department of Periodontology, 61080 Trabzon,
Turkey
(e-mail: esraercan82@gmail.com)
Accepted: December 2014. Submitted: September 2014.
Published Online: February 4, 2015
G 0000 by The EH Angle Education and Research Foundation,
Inc.
reasons. First, the persisting soft tissue folds before
closure, so it is difficult to reach for cleaning and may
serve as a habitat for putative pathogens. Second, long-
term orthodontic therapy may constitute an iatrogenic
trauma for the periodontium.46 Another possible reason
is poorly developed osseous structures.7,8
The few studies that have analyzed the periodontal
status of these persons showed a high incidence of
plaque and bleeding on probing and a high level of
periodontal attachment loss.8,9 In osseous clefts, the
osseous structures are absent or poorly developed in
the region of periodontal supportive tissues.9 Some
reports suggest that the cleft area affects the
periodontal tissues of the teeth in close proximity.10
Researchers comparing sites from teeth adjacent to an
alveolar cleft with unaffected control sites found that
the radiographic alveolar bone level was significantly
more apical at the cleft region, whereas the probing
attachment level was similar in the cleft and control
regions.9,11,12
These findings suggested the presence of a long
connective tissue attachment in the cleft regions.12 The
results of these studies are consistent with the report
of Quirynen et al. 2 that teeth in the cleft had

DOI: 10.2319/092614-691.1 1 Angle Orthodontist, Vol 00, No 0, 0000

2 ERCAN, CELIKOGLU, BUYUK, SEKERCI

Figure 1. Three-dimensional model and axial, coronal, and sagittal views using the SimPlant software.

significantly more bone loss compared with contralat-
eral noncleft control teeth. However, approximal
probing depth and attachment loss values were also
significantly higher than for contralateral teeth. Bone
loss was evaluated by means of parallel intraoral x-
rays using special film holders. Mutthineni et al.9
compared bone loss between patients with unilateral
cleft lip and palate (UCLP) and patients with cleft
palate (CP) using parallel periapical radiographs.9
Patients with UCLP had poorer periodontal status
and higher bone loss than patients with CP.
To our knowledge, no previous study investigated
the bone support of the teeth in patients affected by
cleft lip and palate (CLP) using cone-beam computed
tomography (CBCT). CBCT technology facilitates true
(1:1 size) images without magnification and shows
high intraobserver and interobserver reproducibility
compared with conventional radiographs;1315 thus, it
is important to assess the alveolar bone loss of the
teeth adjacent to the cleft area using CBCT.
The aim of this study was to assess the bone
support of teeth adjacent to the cleft region in patients
affected by UCLP using CBCT and to provide more
specific and detailed data regarding cleft-affected
teeth.
MATERIALS AND METHODS
The present retrospective study was approved by
the local ethics committee of Erciyes University, and all
patients signed an informed consent form allowing
their data to be used for scientific purposes. The
patients were not exposed to any additional radiation
for the purpose of this study.
The present study was conducted using 31 CBCT
scans from patients with unrepaired UCLP (7

Figure 2. Four locations: the crest and sites 1, 2, and 4 mm apical to Figure 3. Measurements for a central incisor on cone-beam
the crest on cone-beam computed tomography sagittal images. computed tomography sagittal images.

Angle Orthodontist, Vol 00, No 0, 0000

BONE LEVEL IN PATIENTS WITH UCLP: A CBCT STUDY
Figure 4. Diagram of measurements on cone-beam computed tomography sagittal images.
females, 24 males; mean age, 13.9 6 2.93 years).The
patients were periodontally healthy and had good oral
hygiene, and no patients had received grafts before
the study. Patients who were smokers were exclud-
ed. All patients were apparently medically normal and
had no history of chemotherapy or radiotherapy.
Patients with distorted or scattered images and the
presence of restorations, root canal treatment,
evident root resorption, or any apical surgery were
also excluded. All images were obtained using a
standardized device (NewTom5G, QR, Verona, Italy)
with a voxel size of 0.125 mm by an experienced
technician. Simplant Pro software (version 13.0,
Materialise HQ, Leuven, Belgium) was used to create
the three-dimensional images, which were trans-
formed to digital imaging and communications in
medicine (DICOM) format. The data were recon-
structed with slices at an interval of 0.25 mm,
positioned parallel to the horizontal axis of the
alveolar bone (Figure 1).
Four teeth were analyzed for each patient affected
by a cleft. Data for the central and canine teeth close
to the cleft area were used as the test, and the
Table 1. Total Number and Position of Analyzed Teeth
Central Canine
Cleft Side Normal Side Cleft Side Normal Side
Number 31 31 18
3
contralateral central and canine teeth were used as
the controls. Because lateral teeth at the cleft area
were absent (in 28 of 31 patients), the contralateral
lateral teeth were not evaluated. For each tooth
analyzed, the distance between the cementoenamel
junction (CEJ) and the bone crest (AC) was mea-
sured, as well as the thickness of the buccal bone
level at 0, 1, 2, and 4 mm, using the Simplant Pro
software (Figures 2 through 4). Measurements were
performed at buccal site of teeth by an experienced
operator.
Statistical Methods
Shapiro-Wilks and Levene variance homogeneity
tests were performed to test the normality of the data
distribution. Because the data were found to be
normally distributed (P . .05), parametric tests were
used. A paired t-test was performed to compare bone
thicknesses at the cleft and healthy sides of the
central and canine teeth in the cleft area. A Students
t-test was used to compare the groups.
To evaluate random error, 15 images were selected
randomly. The same operator conducted all measure-
ments 4 weeks after the first examination and had no
knowledge of the first measurements. According to the
Houston test, calculated to assess the reliability of the
measurements, the values were greater than 0.921,
22 confirming the reliability.
Angle Orthodontist, Vol 00, No 0, 0000
4 ERCAN, CELIKOGLU, BUYUK, SEKERCI

Table 2. Comparison of the Bone Thickness Distribution at Different Levels in Central and Canine Teeth
Central Canine
a b
Bone Thickness Cleft Side Normal Side P Value Cleft Side Normal Side P Value
M0 0.91 6 0.24 1.09 6 0.26 .001 1.24 6 0.69 1.33 6 0.51 .522
M1 1.02 6 0.28 1.04 6 0.27 .700 1.14 6 0.55 1.22 6 0.45 .335
M2 1.11 6 0.38 1.30 6 0.35 .048 1.48 6 0.74 1.32 6 0.61 .366
M4 1.69 6 1.19 1.65 6 0.55 .862 1.66 6 0.58 1.42 6 0.60 .153
a
M0, M1, M2, and M4: thickness of the buccal bone at 0, 1, 2, and 4 mm, respectively.
b
P values determined by paired t-test.

RESULTS
In total, 62 central teeth (31 cleft, 31 contralateral
noncleft region) and 40 canine teeth (18 cleft, 22
contralateral noncleft region) were analyzed (Table 1).
Table 2 presents comparisons of the bone thickness
distribution at different levels of the central and canine
teeth. The bone thickness of central teeth at crest (M0)
was 0.91 6 0.24 mm at the cleft region, and 1.09 6
0.26 mm for the noncleft region. This difference was
statistically significant (P 5 .001). The bone thickness
at 2 mm apical of the alveolar crest (M2) was also
thinner at the cleft region for central teeth. The values
for central teeth were 1.11 6 0.38 mm and 1.30 6
0.35 mm for cleft and noncleft regions, respectively (P
5.048). The values for M1 and M4 for central teeth and
the M0, M1, M2, and M4 measurements for canine
teeth were similar in the cleft and noncleft regions.
The distances between the CEJ and AC are shown
in Table 3. The CEJ-AC distance for central teeth at
the cleft region was 2.34 6 1.09 mm, and 1.53 6
0.69 mm for the noncleft region. This difference was
statistically significant (P 5 .002), confirming that the
bone crest of central teeth was positioned more
apically in the cleft region.
However, distances between CEJ-AC for canine
teeth in cleft and noncleft regions were similar (2.51 6
1.11 and 2.15 6 0.81 mm for cleft and noncleft
regions, respectively; P . .05). The horizontal dis-
tances of teeth in the cleft region were 1.6 6 0.7 mm
for central teeth and 1.9 6 0.9 mm for canine teeth.
This difference was not statistically significant (P .
.05).
DISCUSSION
The radiographic amount of bone loss in teeth
adjacent to a cleft area was evaluated previous-
ly.2,9,11,12,16 Bragger et al.12 reported that radiographic
alveolar bone loss was greater at a cleft site compared
with controls, despite a similar clinical attachment
level. This suggested the presence of a periodontal
attachment apparatus characterized by the presence
of a long supracrestal connective tissue attachment. In
the split-mouth study of Teja et al.,11 the periodontal
conditions and bone levels in patients with unilateral
alveolar cleft were evaluated using parallel periapical
standardized radiographs. The results showed re-
duced bone levels on the both the mesial and distal
surfaces of central teeth adjacent to the cleft,
compared with contralateral control teeth. However,
no difference in the bone level for canines was noted
between cleft and noncleft regions. Quirynen et al.2
evaluated 75 patients with UCLP with regard to
periodontal health status. Radiographic bone loss
was diagnosed when the distance between the CEJ
and AC exceeded 1.5 mm. The results showed that
bone loss was significantly higher for teeth on the cleft
side compared with the contralateral noncleft control
teeth. These results are in agreement with our
findings. However, ours is the first report to evaluate
the bone support of teeth adjacent to the cleft using
CBCT. The results of our study indicated that the bone
thickness of central teeth at crest level (M0) and 2 mm
apical to the crest (M2) were thinner than in the
contralateral noncleft region. Also, the CEJ-AC dis-
tance of central teeth adjacent to the cleft was

Table 3. Mean 6 Standard Deviation, Median, and Interquartile Range CEJ-AC Valuesa
Central Canine
Cleft Side Normal Side Cleft Side Normal Side
CEJ-AC distance 2.34 6 1.09 1.53 6 0.69 2.51 6 1.11 2.15 6 0.81
P valueb .002 .312
a
CEJ-AC is the distance between the cementoenamel junction and the alveolar bone crest.
b
P values determined by Students t-test.

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BONE LEVEL IN PATIENTS WITH UCLP: A CBCT STUDY
significantly higher. Thus, it would seem that alveolar
bone support for central teeth in the cleft region is
important for further periodontal inflammation, bone
loss, and gingival recession. However, there was no
difference for the canine teeth in cleft versus noncleft
regions. In a noncleft study, Papapanou et al.17
reported that incisors showed the highest frequency
of advanced bone loss. This response of central teeth
was also noted for patients with CP in our study,
possibly because canines erupt later than central teeth
and in a more eligible position.
The periodontal status of the teeth close to the cleft
area has been investigated.3,10,1820 Several studies of
periodontal disease progression reported increased
pocket depths, attachment loss, and gingival inflam-
mation at the cleft region versus controls.2,4,8,16,21 Gaggl
et al.7 analyzed several types of cleft, including UCLP,
CP, and bilateral CLAP. Patients with UCLP and
bilateral CLAP showed a greater number of periodon-
tal lesions in the maxillary front tooth region compared
with the general population. However, some studies
have reported that the periodontal disease was similar
to that in other noncleft populations and the teeth close
to cleft area were not at greater risk than those in
noncleft regions.3,10,20 These variations may be due to
differences in the study populations in terms of oral
hygiene status, education, and socioeconomic status,
and methodologic differences. In our study, we
analyzed nontreated patients with UCLP using CBCT
technology retrospectively. The advantages of the
CBCT technology have been previously reported.2224
In subjects with CLP, it is difficult to maintain oral
hygiene because of oronasal communication.4 Stec et
al.19 compared cleft and noncleft general populations
and reported high plaque indices close to the cleft
area. Perdikogianni et al.1 analyzed the oral hygiene
and periodontal status of children and adolescents with
CLAP. The cleft group had poorer oral hygiene
compared with the control group, and teeth in the cleft
region showed higher levels of periodontopathogens.
Salvi et al.8 examined 26 subjects who were not
enrolled in a supportive periodontal therapy program
and concluded that cleft sites with high plaque and
gingival inflammation scores showed more periodontal
tissue destruction than control sites.
In the area of the developmental defect, a long sup-
racrestal connective tissue attachment without complete
bone support was reported by Bragger et al.12 However,
this long connective tissue attachment does not consti-
tute a locus minoris resistentiae for the progression
of periodontal inflammation.8 Similarly, plaque scores in
the cleft region were high and the mean full-mouth
probing depth (PD) and clinical attachment level (CAL)
scores deteriorated significantly over 25 years.19,21
5
CONCLUSIONS
N The bone thickness of the central incisor at the crest
and 2 mm apically was statistically significantly
thinner at the cleft region (P , .01). However, the
values for M1 and M4 for central teeth as well as M0,
M1, M2, and M4 measurements for canine teeth
were similar in the cleft and noncleft regions.
N The mean CEJ-AC distance for central teeth in the
cleft region was 2.34 6 1.09 mm, compared with
1.53 6 0.69 mm for the noncleft region (P 5 .002),
while these distances for canine teeth in the cleft and
noncleft regions were similar.
N Reduced bone support might cause several prob-
lems in the future. Thus, regular and strict profes-
sional dental control is essential for maintaining the
periodontal health of these patients.
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