Odborna praâce ORTODONCIE

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Tvar zubnõÂho oblouku po uzaÂveÏru rozsÏteÏpoveÂho 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.

OddeÏlenõ ortodoncie a rozsÏteÏpovyÂch vad Stomatologicke kliniky 3. LF UK FNKV Praha

Department of Orthodontics and Cleft Defects, Clinic of Stomatology, 3rd Medical Faculty of Charles University, University HospitalKraÂlovske Vinohrady, Prague

Souhrn

UzavõÂraÂnõ mezery v mõÂsteÏ rozsÏteÏpoveÂho defektu posunem zubuÊ fixnõÂm ortodontickyÂm aparaÂtem umozÏnÏuje funkcÏnõ a estetickou rehabilitaci chrupu bez nutnosti zhotovenõ proteticke naÂhrady. Na 40 okluzogramech u 20 pacientuÊ s celkovyÂm jednostrannyÂm rozsÏteÏpem byl analyzovaÂn rozsah a charakter ortodontickyÂch posunuÊ zubuÊ prÏi uzaÂveÏru rozsÏteÏpoveÂho defektu. Byl nalezen rozdõÂlny charakter zmeÏn v postavenõ a pohybech zubuÊ ve velkeÂm rozsÏteÏpoveÂm segmentu cÏelisti u pravostranneÂho a levostranneÂho celkoveÂho rozsÏteÏpu, ke kteryÂm dosÏlo prÏi uzavõÂ-raÂnõ rozsÏteÏpoveÂho defektu chrupu a uÂpraveÏ tvaru hornõÂho zubnõÂho oblouku fixnõÂm ortodontickyÂm aparaÂtem (Orto-doncie 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).

KlõÂcÏova slova:celkovy jednostranny rozsÏteÏp, fixnõ aparaÂt, ortodonticky uzaÂveÏr defektu chrupu, zmeÏny postavenõ zubuÊ

Key words:complete unilateral cleft, fixed orthodontic appliance, orthodontic closure of the space in dentition, changes in the teeth position

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 UÂvod

RozsÏteÏpy v orofaciaÂlnõ oblasti jsou jednou z nejcÏa-steÏjsÏõÂch vrozenyÂch vyÂvojovyÂch vad. V CÏeske republice je dlouhodoba incidence vyÂskytu 1,8-2 na 1000 zÏiveÏ narozenyÂch deÏtõ [1, 2, 3]. Charakter defektu ma teÏzÏke negativnõ duÊsledky na polykaÂnõÂ, dyÂchaÂnõÂ, kousaÂnõÂ, a tvorbu rÏecÏi. U 20% postizÏenyÂch je rozsÏteÏp kombino-vaÂn s dalsÏõ zdravotnõ zaÂteÏzÏõ [4, 5]. Plna rehabilitace

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those patients requires a long-time and demanding multidisciplinary treatment [6]. Currently, the medical science is not able to eliminate the anomaly comple-tely [7]. As the secondary deformities and defective speech significantly contribute to the lower quality of life of an otherwise healthy individual, the treatment fo-cuses to minimize the defects in appearance and func-tions of structures affected by the anomaly [8]. Final adjustment of the dentition with fixed orthodontic ap-pliance 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 ad-justment 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 pa-tients. All the patients underwent orthodontic treat-ment according to the same treattreat-ment protocolat the Department of Orthodontics and Cleft Defects, Cli-nic of Stomatology, 3rd Medical Faculty of Charles University, University HospitalKraÂlovske Vinohrady, Prague. The mean length of the treatment with fixed orthodontic appliance was 3 years, including the re-tention phase with the current fixed appliance that was not further activated.

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 mar-ked on the outer curve of the dentalarch perimeter, mesially off both first permanent maxillary molars: tips of buccal cusps of maxillary premolars, tips of maxil-lary canines, and centres of cutting edges of maxilmaxil-lary incisors (Fig. 1).

Results of individual measurements performed in models of dentition, in photographs of the models, and in occlusograms were compared. Multiple measu-teÏchto pacientuÊ vyzÏaduje dlouhotrvajõÂcõÂ naÂrocÏnou

mul-tidisciplinaÂrnõ leÂcÏbu [6]. UÂplneÏ odstranit vadu soucÏasna leÂkarÏska veÏda nedokaÂzÏe [7]. ProtozÏe sekundaÂrnõ defor-mity a vadny mluveny projev mohou vyÂznamneÏ prÏispõÂ-vat ke snõÂzÏenõ kvality zÏivota jinak zcela zdraveÂho je-dince, je leÂcÏba zameÏrÏena na minimalizaci nedostatkuÊ vzhledu a funkce postizÏenyÂch struktur[8]. KonecÏna uÂprava chrupu fixnõÂm ortodontickyÂm aparaÂtem by meÏl a byÂt u pacientuÊ s rozsÏteÏpem samozrÏejmostõÂ. IdeaÂlnõ variantou je uzaÂveÏr rozsÏteÏpoveÂho defektu chrupu posunem zubuÊ bez nutnosti proteticke rekon-strukce. Dany stav je trÏeba udrzÏet stabilneÏ co nejdeÂl e [9, 10]. Autorky povazÏujõ analyÂzu zmeÏn postavenõ zubuÊ v pruÊbeÏhu ortodonticke l eÂcÏby za velice duÊl ezÏity faktor ovlivnÏujõÂcõ stabilitu vyÂsledku leÂcÏby fixnõÂm aparaÂtem. CõÂ-lem prÏedklaÂdane praÂce je proto analyÂza zmeÏn v posta-venõ jednotlivyÂch zubuÊ po uzaÂveÏru rozsÏteÏpoveÂho de-fektu chrupu posunem zubuÊ fixnõÂm ortodontickyÂm aparaÂtem u pacientuÊ s celkovyÂm jednostrannyÂm roz-sÏteÏpem hornõ cÏelisti.

MateriaÂl

Bylo analyzovaÂno 40 okluzogramuÊ saÂdrovyÂch mo-deluÊ chrupu 20 pacientuÊ s celkovyÂm jednostrannyÂm rozsÏteÏpem hornõ cÏelisti prÏed a po uÂpraveÏ tvaru hornõÂho zubnõÂho oblouku fixnõÂm aparaÂtem ve smyslu uzaÂveÏru rozsÏteÏpoveÂho defektu chrupu posunem zubuÊ. 12 pa-cientuÊ meÏlo celkovy levostranny rozsÏteÏp a 8 papa-cientuÊ meÏlo celkovy pravostranny rozsÏteÏp hornõ cÏelisti, 14 pa-cientuÊ byli muzÏi a 6 papa-cientuÊ byly zÏeny. VsÏichni pacienti byli ortodonticky leÂcÏeni podle stejneÂho l eÂcÏebneÂho pro-tokolu na OddeÏlenõ ortodoncie a rozsÏteÏpovyÂch vad Sto-matologicke kliniky FNKV Praha. PruÊmeÏrna doba leÂcÏby fixnõÂm aparaÂtem byla 3 roky, vcÏetneÏ kladenõ duÊrazu na dostatecÏnou retencÏnõ faÂzi ortodonticke terapie staÂvajõÂ-cõÂm fixnõÂm aparaÂtem, ktery uzÏ nebyldaÂle aktivovaÂn.

Metodika

Na kazÏdeÂm saÂdroveÂm modelu prÏed zahaÂjenõ orto-donticke l eÂcÏby fixnõÂm aparaÂtem a po sejmutõ fixnõÂho aparaÂtu bylo vyznacÏeno 10 sledovanyÂch boduÊ na zevnõ krÏivce perimetru zubnõÂho oblouku meziaÂl neÏ od obou prvnõÂch staÂl yÂch hornõÂch molaÂruÊ. Byly to tyto body: vr-choly bukaÂlnõÂch hrbolkuÊ hornõÂch premolaÂruÊ, hroty hor-nõÂch sÏpicÏaÂkuÊ a strÏedy rÏezacõÂch hran horhor-nõÂch rÏezaÂkuÊ (obr. 1).

Byly porovnaÂny vyÂsledky jednotlivyÂch meÏrÏenõÂ na saÂdrovyÂch modelech chrupu, na fotografiõÂch

saÂdro-Obr. 1:Okluzogram s vyznacÏenyÂmi body Fig. 1:Occlusogram with points marked

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rements showed that the most accurate results were obtained in occlusograms. They were, therefore, cho-sen 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 tran-sversaldirection (axis x) were recorded. Axis x was de-termined as the straight line bisecting the angle bet-ween 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 occluso-gram 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 occlu-sogram. Then the occlusogram with axes x and y and reference points marked after the treatment was inser-ted under the millimeter paper. Points after the treat-ment 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 (transver-saldirection), and on y - axis (anteroposterior direction).

On x - axis (transversally) in the whole sample the positive sign always meant movement ¹to palatal su-tureª, 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 ne-gative 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 to-ward 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 vyÂch modeluÊ a na okluzogramech. VõÂcecÏetnyÂm

meÏrÏe-nõÂm bylo zjisÏteÏno, zÏe nejprÏesneÏjsÏõ vyÂsledky byly opako-vaneÏ zmeÏrÏeny na okluzogramech, ktere byly proto zvo-leny jako nejvhodneÏjsÏõ pro definitivnõ meÏrÏenõÂ.

Na okluzogramech byly stanoveny na milimetrove sõÂti osy x a y, na nichzÏ jsme vyjaÂdrÏili zmeÏny v postavenõ zubuÊ v rozsahu 5+ azÏ +5 ve smeÏru anteroposteriornõÂm (osa y) a transverzaÂl neÏ (osa x). Osa x byla urcÏena jako prÏõÂmka puÊl õÂcõ uÂhel mezi liniõ spojujõÂcõ body lezÏõÂcõ nejdi-staÂl neÏji na obvodu klinicke korunky zubuÊ 6+6 a mezi li-niõ spojujõÂcõ body lezÏõÂcõ nejmeziaÂl neÏji na obvodu kli-nicke korunky 6+6 (Obr. 2). U pacientuÊ s levostrannyÂm rozsÏteÏpem osa y tvorÏõ tecÏnu k bodu lezÏõÂcõÂmu nejlateraÂl -neÏji na konvexiteÏ zubu 6+, u pravostranneÂho rozsÏteÏpu v bodu umõÂsteÏneÂmu nejlateraÂl neÏji na konvexiteÏ zubu +6. Hodnocenõ dentaÂlnõÂch zmeÏn bylo provedeno na pruÊsvitneÂm papõÂrÏe, na ktery byla pro prÏesny odecÏet zkopõÂrovaÂna milimetrova sõÂt'.

DaÂle byl okluzogram s vyznacÏenyÂm krÏõÂzÏem, ktery znaÂzornÏuje osu x a y vlozÏen pod pruÊsvitny papõÂr tak, aby se osy na milimetroveÂm papõÂrÏe a na okluzogramu prÏekryÂvaly. Zvolene referencÏnõ body prÏed leÂcÏbou a po leÂcÏbeÏ byly prÏeneseny na milimetrovy papõÂr. NejdrÏõÂve byly na okluzogramu vyznacÏeny body prÏed leÂcÏbou. Pote bylmilimetrovy papõÂr s jizÏ existujõÂcõÂm krÏõÂzÏem podlozÏen okluzogramem s osami x a y, ale tentokraÂt s referencÏnõÂmi body zaznamenanyÂmi po leÂcÏbeÏ. Body znacÏene po l eÂcÏbeÏ byly odlisÏeny od boduÊ prÏed leÂcÏbou jinou barvou (Obr. 3). Pro kazÏdy zub byly odecÏteny zmeÏny na ose x (transver-zaÂlnõ smeÏr) a na ose y (anteroposteriornõ smeÏr).

Na ose x (transverzaÂl neÏ) v celeÂm souboru kladne znameÂnko vzÏdy znamenalo posun ¹k patroveÂmu sÏvuª a zaÂporne znameÂnko vzÏdy posun ¹od patroveÂho sÏvuª.

Na ose y (anteroposteriorneÏ), pokud dosÏlo k posunu zubu smeÏrem anteriornõÂm, oznacÏujeme vyÂsledek v kladnyÂch hodnotaÂch a naopak, pokud dosÏlo k po-sunu zubu smeÏrem posteriornõÂm, vyjadrÏujeme vyÂsle-dek v zaÂpornyÂch hodnotaÂch.

VesÏkere zõÂskane uÂdaje byly zpracovaÂny programem SPSS verze 15, SPSS Inc. Chicago, USA.

VyÂsledky

1. Pacienti s celkovyÂm levostrannyÂm rozsÏteÏpem. JednovyÂbeÏrovyÂmi t-testy bylo prokaÂzaÂno, zÏe k pa-troveÂmu sÏvu se posunuly 3+, 2+ a 1+, od patroveÂho sÏvu se posunuly +1, +3, +4 a +5. PosteriorneÏ se posu-nulzub +1, anteriorneÏ se posunuly +3, +4 a +5. U ostat-Obr. 2:Konstrukce osy x

Fig. 2:Construction of the x- axis

Obr. 3:ReferencÏnõÂ body na milimetro-veÂm papõÂru. ModrÏe - stav prÏed leÂcÏbou a cÏerveneÏ - po leÂcÏbeÏ .

Fig. 3:Reference points in the milli-meter paper grid. Blue - situation prior to treatment, red - situation after treat-ment

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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).

nõÂch zubuÊ nedosÏlo k statisticky vyÂznamneÂmu posunu na uÂrovni p<0,05 (Tabulka 1, Obr. 4).

2. Pacienti s celkovyÂm pravostrannyÂm rozsÏteÏpem JednovyÂbeÏrovyÂmi t-testy bylo prokaÂzaÂno, zÏe od pa-troveÂho sÏvu se posunuly 4+, +4 a +5. U ostatnõÂch zubuÊ nedosÏlo k statisticky vyÂznamneÂmu posunu na uÂrovni p <0,05 (Tabulka 1, Obr. 5). 5+ 4+ 3+ 2+ 1+ +1 +2 +3 +4 +5 N 12 10 11 9 12 12 2 12 11 12 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 Min. -6.0 -3.5 .0 1.5 -.5 -7.0 -3.0 -11.0 -6.5 -9.0 Left cleft x-axis 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 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 Min. -.5 -2.0 -5.0 -3.5 -5.0 -4.5 2.0 -2.0 -3.0 -1.5 Left cleft y-axis 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 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 Min. -3.5 -3.5 -3.5 .0 -3.0 -3.5 -4.0 -3.0 -3.0 -3.5 Right cleft x-axis 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 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 Min. -.5 -1.0 .0 1.0 -2.5 -2.5 -1.5 -3.5 -2.5 -1.5 Right cleft y-axis 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. Tabulka 1:Posuny zubuÊ u levostranneÂho a pravostranneÂho rozsÏteÏpu v ose x a y

Table 1:Movements of teeth in left-side and right-side clefts in the axes x and y

Obr. 4:Posuny zubuÊ po l eÂcÏbeÏ fixnõÂm aparaÂtem u celkoveÂho levo-stranneÂho rozsÏteÏpu. Statisticky vyÂznamne zmeÏny jsou znaÂzorneÏny cÏerveneÏ.

Fig. 4:Movement of teeth after treatment with fixed appliance in pa-tients with a complete unilateral cleft on the left. Statistically signifi-cant changes are in red.

Obr. 5:Posuny zubuÊ po l eÂcÏbeÏ fixnõÂm aparaÂtem u celkoveÂho pravo-stranneÂho rozsÏteÏpu. Statisticky vyÂznamne zmeÏny a smeÏr pohybuÊ jsou znaÂzorneÏny cÏerveneÏ.

Fig. 5:Movement of teeth after treatment with fixed appliance in pa-tients with a complete unilateral cleft on the right. Statistically signi-ficant changes are in red.

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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 posi-tion 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 ove-rall relationship between the upper and lower dental ar-ches, 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 orthodon-tic therapy was applied, without prostheorthodon-tic reconstruc-tion or dental implants. At the same time we also wan-ted to work with the sample including patients who were operated at approximately the same age and ac-cording to the same surgery protocol- because the morphology of the cleft jaw is significantly determined by surgicalinterventions [14, 15]. We wanted to iden-tify how extensive and what orthodontic movements were required for the closure of the cleft defect through the orthodontic teeth movement, which is the least in-vasive approach and the most comfortable method for a patient. The prosthetic treatment - though it is suita-ble - 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 pro-sthetic 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 mesiali-sation of the lateral segment is the best method for the dentalarch restoration. Nevertheless, it is a very demanding technique which requires some modifica-tions of treatment protocol.

In a complete unilateral maxillary cleft we can find si-milar type of orthodontic movements and sisi-milar morphological response to the treatment in the ante-rior 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. Diskuse

TeÂmatem prÏedklaÂdane praÂce bylo popsat morfolo-gicke zmeÏny zubnõÂho oblouku, prÏesneÏji zmeÏny v posta-venõ jednotlivyÂch zubuÊ hornõ cÏelisti u pacienta s celko-vyÂm jednostrannyÂm rozsÏteÏpem po leÂcÏbeÏ fixnõÂm aparaÂ-tem. ZaÂrovenÏ jsme porovnali zmeÏny v postavenõ zubuÊ v maleÂm a velkeÂm segmentu hornõ cÏelisti po leÂcÏbeÏ mezi skupinami pacientuÊ s celkovyÂm levostrannyÂm a pravo-strannyÂm rozsÏteÏpem. A to proto, zÏe v odborne litera-turÏe jsou uÂdaje, ktere popisujõ tvar zubnõÂho oblouku u pacienta s rozsÏteÏpem, spõÂsÏe zameÏrÏeny na celkovy vztah hornõÂho a dolnõÂho zubnõÂho oblouku, nebo vztah jednotlivyÂch zubuÊ, cozÏ vyjadrÏujõ naprÏõÂklad Goslon Yar-dstick nebo Huddart Bodenham skoÂre [11, 12, 13]. NaÂsÏ soubor pacientuÊ tvorÏili pacienti s teÏzÏkyÂm typem rozsÏteÏ-poveÂho defektu, avsÏak pro uÂpravu tvaru zubnõÂho ob-louku byla pouzÏita pouze ortodonticka terapie bez vy-uzÏitõ proteticke rekonstrukce nebo dentaÂlnõ implanto-logie. ZaÂrovenÏ jsme hledali takovy soubor, kde pacienti byli operovaÂni prÏiblizÏneÏ ve stejneÂm veÏku podle stejneÂho chirurgickeÂho protokolu a to z toho duÊvodu, zÏe morfologie rozsÏteÏpove cÏelisti je znacÏneÏ determino-vaÂna chirurgickyÂmi intervencemi [14, 15]. ChteÏli jsme veÏdeÏt, jak velke a jake ortodonticke posuny bylo trÏeba pro uzaÂveÏr rozsÏteÏpoveÂho defektu pouze ortodontic-kyÂm posunem zubuÊ, cozÏ je pro pacienta nejmeÂneÏ inva-zivnõ a nejmeÂneÏ zateÏzÏujõÂcõ rÏesÏenõÂ. Proteticke rÏesÏenõÂ, i kdyzÏ je vyhovujõÂcõÂ, ma cÏasoveÏ omezenou trvanlivost a s preparacõ pilõÂrÏovyÂch zubuÊ se biologicky faktor chrupu jizÏ u velmi mladyÂch jedincuÊ vyÂznamneÏ sni-zÏuje[16]. Rezervy pro dalsÏõ rÏesÏenõ po uplynutõ doby funkcÏnõ a esteticke zÏivotnosti proteticke praÂce jsou di-skutabilnõÂ[17]. RovneÏzÏ rekonstrukce rozsÏteÏpoveÂho de-fektu dentice dentaÂlnõÂm implantaÂtem nenõ ani u neroz-sÏteÏpoveÂho pacienta dozÏivotnõ a musõÂme si rovneÏzÏ po-klaÂdat otaÂzku, jak budeme postupovat v terapii daÂl e, pokud invazivneÏjsÏõ postupy indikujeme u mladyÂch pa-cientuÊ jako prvnõ rÏesÏenõ [18]. UzaÂveÏr rozsÏteÏpoveÂho de-fektu chrupu postupnou mezializacõ lateraÂl nõÂho uÂseku je, dle rÏady autoruÊ, nejvhodneÏjsÏõÂm zpuÊsobem rekon-strukce zubnõÂho oblouku. PatrÏõ vsÏak k nejnaÂrocÏneÏjsÏõÂm a vyzÏaduje urcÏite modifikace leÂcÏebneÂho protokolu.

U celkoveÂho jednostranneÂho rozsÏteÏpu hornõ cÏelisti nachaÂzõÂme obdobny typ ortodontickyÂch posunuÊ a ob-dobnou morfologickou odpoveÏd' na l eÂcÏbu jednak ve frontaÂlnõÂm uÂseku zubnõÂho oblouku a daÂle v oblasti u sÏpi-cÏaÂku a premolaÂruÊ maleÂho segmentu. Uvedene zuby maleÂho segmentu se pohybujõ anteriorneÏ a vestibu-laÂrneÏ. Anteriornõ cÏaÂst chrupu velkeÂho segmentu se oplosÏt'uje, zuby se pohybujõ smeÏrem oraÂlnõÂm. Jako nej-cÏasteÏji nespraÂvneÏ postavene zuby hodnotõÂme premo-laÂry velkeÂho segmentu.

U celkoveÂho jednostranneÂho rozsÏteÏpu hornõÂ cÏelisti se lisÏõÂ mõÂra a typ zmeÏn v postavenõÂ zubuÊ po l eÂcÏbeÏ u

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pra-In a complete unilateral maxillary cleft the extension and types of changes in teeth positions after the treat-ment 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 an-terior 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 fect, the teeth of the frontalsegment move off the cleft de-fect. The oralinclination or movement is the same as in the case of the left-side defect. This fact may be impor-tant for surgeon requirements regarding the dimensions of the cleft defect prior to reconstruction of alveolar pro-cess 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 ortho-dontic correction) to open the cleft defect with incisors protrusion (when we modify the space before spongio-plasty) in case we want to close the defect with teeth mo-vement. Therefore, spongioplasty should be well planned and there should be prepared also the following treat-ment methods. When mesialmovetreat-ments are employed, the space should be solved especially with the movement of lateral teeth of the small segment in vestibular direc-tion. We have to take into account the location of the ca-nine. 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 dif-ferent morphology of the dental arch (and thus also ne-cessary therapeutic alterations in teeth positions) in both types of a complete cleft, or that in case of the cleft loca-ted on the right the deformity of the dentalarch is less pro-nounced. The shape of the dentalarch and interdigitation of teeth are important factors of the stability of the ortho-dontic treatment results. In the patient with a complete cleft we have to stabilize not only the position of teeth af-ter treatment, but also transversal dimensions of the re-constructed palate, and prevent the collapse of lateral se-gments due to scar pull.

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 patientswith a com-plete unilateral cleft. Though the morphology of the dentalarch is - at the end of the treatment - considera-bly determined by surgical interventions, we found sta-tistically significant changes in the position of teeth af-ter 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 chan-ges are different for clefts located on the left side and vostranneÂho a levostranneÂho typu defektu ve velkeÂm

segmentu. To je skutecÏnost, ktera naÂs zaujala, zatõÂm pro ni nemaÂme vysveÏtlenõ a jeho hledaÂnõ bude vyzÏado-vat prÏedevsÏõÂm zpracovaÂnõ veÏtsÏõÂch souboruÊ pacientuÊ.

U obou typuÊ rozsÏteÏpu se meÏnõ postavenõ zubuÊ fron-taÂl nõÂho uÂseku chrupu, ktery tvorÏõ zuby prÏednõÂho poÂl u velkeÂho segmentu. U levostranneÂho rozsÏteÏpu se vsÏechny zuby anteriornõÂho poÂlu velkeÂho segmentu po-sunujõ oraÂl neÏ a smeÏrem k rozsÏteÏpoveÂmu defektu. Chceme-li dosaÂhnout uzaÂveÏru mezery u pravostran-neÂho rozsÏteÏpu, pohybujõ se zuby frontaÂl nõÂho uÂseku prÏekvapiveÏ smeÏrem od rozsÏteÏpoveÂho defektu. PotrÏeba oraÂlnõÂho sklonu cÏi posunu je opeÏt stejnaÂ, jako u levo-stranneÂho rozsÏteÏpu. Tato skutecÏnost muÊzÏe byÂt duÊl e-zÏita prÏi realizaci pozÏadavkuÊ chirurga na rozmeÏry roz-sÏteÏpoveÂho defektu prÏed rekonstrukcõ alveolaÂrnõÂho vyÂ-beÏzÏku spongioÂznõ kostõ (tzv. spongioplastikou). Znamena to totizÏ, zÏe u pravostranneÂho rozsÏteÏpu nenõ vhodne (pokud nenõ prÏõÂtomen obraÂceny skus plaÂno-vany k ortodonticke korekci) prÏi uÂpraveÏ mezery prÏed doplneÏnõÂm kosti otevõÂrat rozsÏteÏpovy defekt protruzõ rÏe-zaÂkuÊ, chceme-li naÂsledneÏ rozsÏteÏpovy defekt chrupu uzavrÏõÂt posunem zubuÊ. PrÏi spongioplastice by tudõÂzÏ meÏl byÂt jasny dalsÏõ terapeuticky pl aÂn. V prÏõÂpadeÏ mezi-aÂlnõÂch posunuÊ by se mezera meÏl a prÏedevsÏõÂm upravo-vat pohybem lateraÂlnõÂch zubuÊ maleÂho segmentu smeÏ-rem vestibulaÂrnõÂm. NavõÂc prÏitom musõÂme respektovat mõÂsto pro sÏpicÏaÂk. NasÏe soubory jsou velmi male na to, abychom nalezene skutecÏnosti mohli zobecnÏovat. ZõÂskane vyÂsledky je trÏeba oveÏrÏit, protozÏe mohou na-znacÏovat i poneÏkud jinou morfologii zubnõÂho oblouku (a tedy mõÂry nutnyÂch terapeutickyÂch zmeÏn v postavenõ zubuÊ) u obou typuÊ celkovyÂch rozsÏteÏpuÊ a nebo, zÏe u pra-vostranneÂho rozsÏteÏpu nenõ rozsÏteÏpova deformace tvaru zubnõÂho oblouku tak vyÂraznaÂ. Tvar zubnõÂho ob-louku a interkuspidace jsou duÊl ezÏite pro stabilitu vyÂ-sledku ortodonticke l eÂcÏby. U pacienta s celkovyÂm roz-sÏteÏpem ovsÏem musõÂme dlouhodobeÏ stabilizovat nejen postavenõ zubuÊ po l eÂcÏbeÏ, ale i transverzaÂlnõ rozmeÏry rekonstruovaneÂho patra a braÂnit kolapsu lateraÂlnõÂch uÂsekuÊ tahem jizvy.

ZaÂveÏr

CõÂlem praÂce bylo zhodnotit typ a rozsah zmeÏn v po-stavenõÂzubuÊ po l eÂcÏbeÏ fixnõÂm aparaÂtem u pacientas cel-kovyÂm jednostrannyÂm rozsÏteÏpem. I kdyzÏ je morfologie oblouku na konci leÂcÏby do znacÏne mõÂry determinovaÂna chirurgickyÂmi intervencemi, nasÏli jsme statisticky vyÂ-znamne zmeÏny v postavenõ zubuÊ po l eÂcÏbeÏ a prokaÂzali jsme urcÏite spolecÏne znaky pro pohyby zubuÊ v maleÂm segmentu rozsÏteÏpove cÏelisti a ve frontaÂlnõÂm uÂseku chrupu. ZmeÏny v postavenõ zubuÊ ve velkeÂm segmentu rozsÏteÏpove cÏelisti se vsÏak u levostranneÂho a pravo-stranneÂho rozsÏteÏpu l isÏõÂ. Pokud se tyto naÂlezy potvrdõÂ

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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.

na veÏtsÏõÂch souborech pacientuÊ, mohly by prÏispeÏt k efektivneÏjsÏõÂmu sestavenõÂ plaÂnu l eÂcÏby u jednotlivyÂch typuÊ rozsÏteÏpuÊ.

PodeÏkovaÂnõÂ: Autorky deÏkujõ Mgr. KaterÏineÏ Langove za vyÂznamnou pomoc prÏi statistickeÂm zpracovaÂnõ vyÂ-sledkuÊ praÂce.

AutorÏi nemajõ komercÏnõÂ, vlastnicke nebo financÏnõ zaÂjmy na pro-duktech nebo spolecÏnostech popsanyÂch v tomto cÏlaÂnku.

Literatura/References

1. Peterka, M.: PrÏõÂcÏiny vzniku vrozenyÂch vad, jejich leÂcÏba a prevence. Praha: Akademie veÏd CÏeske 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. VanÏkova Z., Urbanova W., Kot'ova M.: Incidence

rozsÏteÏpovyÂch vad hornõ cÏelisti v cÏeske populaci v letech 2000 -2006. Studentska veÏdecka konference 2. LF UK, 7.-8. 4. 2010.

4. DusÏkovaÂ, M. a kol.: Pokroky v sekundaÂrnõÂ leÂcÏbeÏ nemoc-nyÂch s rozsÏteÏpem. Hradec KraÂloveÂ: Olga CÏermaÂkovaÂ, 2007.

5. Gilmore, S. I.; Hofman, S. M.: Clefts in Wisconsin: Inci-dence and related factors. Cleft Palate J. 1966, 3, s. 186-199.

6. ZÏizÏka, J.: DiagnoÂza syndromuÊ a malformacõÂ. Praha: Ga-leÂn, 1994.

7. Kot'ovaÂ, M.; Peterka, M.; Urban, F.; SÏmahel, 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 high-dose folic acid and multivitamins. Teratology. 1995, 51, cÏ. 2, s. 71-78.

9. UrbanovaÂ, W.: Ortodonticka prechirurgicka l eÂcÏba u pa-cienta s rozsÏteÏpem. Odborna atestacÏnõ praÂce z oboru ortodoncie. Praha, 2007.

10. KleidienstovaÂ, Z.: AnomaÂlie v pocÏtu zubuÊ u pacienta s rozsÏteÏpem. Odborna atestacÏnõ praÂce z oboru ortodon-cie. Praha, 2006.

11. Heidbuchel, K.L.; Kuijpers-Jagtman, A.M.: Maxillary and mandibular dental-arch dimensions and occlusion in bi-lateral 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 pa-tients. Angle Orthodont. 2006, 76, cÏ. 5, s. 810-816. 13. Hermann, N. V.; Jensen, B. L.; Dahl, E.; Bolund, S.;

Dar-vann, T. A.; Kreiborg, S.: Craniofacialgrowth in subjects with unilateral complete cleft lip and palate, and unilate-ral incomplete cleft lip, from 2 to 22 months of age. J. cra-niofac. 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. re-constr. 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. SÏmahel, Z.; MuÈllerovaÂ, Z.: RuÊst a vyÂvoj oblicÏeje u roz-sÏteÏpuÊ rtu a/nebo patra: I. KraniofaciaÂlnõÂ odchylky, jejich prÏõÂcÏiny a duÊsledky. CÏes. 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.; Moo-ney, M. P.; Dusdieker, L. B.: Lip pressure changes follo-wing lip repair in infants with unilateral clefts of the lip and palate. Plast. reconstr. Surg. 1984, 74, cÏ. 4, s. 476-481.

MUDr. Helena KopovaÂ

Stomatologicka klinika FNKV Praha SÏrobaÂrova 50, 100 34 Praha 10

ROD a. s. porÏaÂdaÂ

14. 10. 2011

PrÏednaÂsÏejõÂcõÂ:

Dr. Aladin Sabbagh

MõÂsto konaÂnõÂ:

Praha

TeÂma:

¹Troubleshooting in Orthodontic Treatmentª

Co deÏlat kdyzÏ nastane probleÂm prÏi leÂcÏbeÏ? ± prÏednaÂsÏka v anglicÏtineÏ

ROD a. s., Na SaÂdce 780/20, 149 00 Praha 4,

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