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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 167-172

Evaluation of dental arch relationship of patients with bilateral cleft lip and palate applying bilateral yardstick


1 Departament of Orthodontics, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil
2 National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

Date of Web Publication21-Nov-2017

Correspondence Address:
Cristiane Lucas de Farias Luz
Rua Silvio Marchione, 3-20, Vila Universitária, Bauru, São Paulo
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_29_17

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  Abstract 

Aims: This study aims to verify the applicability and reliability of the Bilateral yardstick on the assessment of interarch relationship in patients with bilateral cleft lip and palate (BCLP) through three-dimensional (3D) virtual casts. Setting and Design: A total of 112 individuals with BCLP, aging 6–12 years old, with no associated syndromes, free from previous orthodontic treatment and from secondary bone grafting. Methods: Plaster casts from the 112 individuals were obtained, randomly numbered and scanned, generating a 3D digital image. Three calibrated orthodontists used the Bilateral yardstick to classify, in two rounds, the interarch relationship on the virtual casts. Descriptive statistics were employed to describe the frequencies of the scores of the Bilateral yardstick. Weighted Kappa statistics were calculated to determine intra- and inter-rater reliability. Results: Raters reported no difficulties in the employment of the Bilateral yardstick on 3D virtual casts. Good occlusal relationship or minor deviation was observed in 60 (53.6%) individuals. No more than 13 (11.6%) patients were classified as having a poor arch form. Intraexaminer kappa values were higher than 0.93 (confidence interval [CI] 0.88–0.98), and interexaminer agreement was higher than 0.78 (CI 0.69–0.87). Conclusion: Bilateral yardstick proved to be applicable to the assessment of dental arch relationship of patients with BCLP through 3D virtual casts. Weighted kappa values indicated good intrarater and good-to-very good agreement, supporting the reliability of this yardstick when employed to virtual casts. Further studies should be encouraged to face the actual lack of evidence in this field.

Keywords: Bilateral, cleft lip, imaging/three-dimensional, orthodontics, palate


How to cite this article:
de Farias Luz CL, Ozawa TO, Arouca R, Ohashi A, Broll D. Evaluation of dental arch relationship of patients with bilateral cleft lip and palate applying bilateral yardstick. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:167-72

How to cite this URL:
de Farias Luz CL, Ozawa TO, Arouca R, Ohashi A, Broll D. Evaluation of dental arch relationship of patients with bilateral cleft lip and palate applying bilateral yardstick. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:167-72. Available from: https://www.jclpca.org/text.asp?2017/4/3/167/218869


  Introduction Top


Occlusal discrepancies are frequent in patients with cleft lip and palate, for the most part, due to the adverse effects of primary surgeries. These deviations, which generally interfere with treatment planning and prognostication, ought to be early diagnosed in order to ensure the provision of a proper healthcare and the best occlusal outcomes. That requires the constant monitoring of the rehabilitation process by specific orthodontic evaluation methods.

Occlusal yardsticks especially conceived for patients with cleft lip and palate have been developed with the goal to define classification systems that would precisely describe, through scores, the severity of the deviations on dental arch relationship. For each yardstick, a different method of classification is set, considering validity, reliability, precision, and simplicity requirements to be fulfilled.[1],[2],[3]

Some of these yardsticks have already proved its value on the clinical evaluation of dental arch relationship in patients with unilateral cleft lip and palate (UCLP), as well as on the comparison of the results achieved by the different protocols applied by craniofacial anomalies rehabilitation centers worldwide. Among these yardsticks, the one proposed by Atack et al.[4] and the Goslon yardstick[5] stand out as the most frequently used for these purposes, chiefly because of their simplicity and reliability.[4],[5],[6],[7],[8],[9],[10] Contrariwise, the assessment of occlusal conditions in patients with bilateral cleft lip and palate (BCLP) is not yet fully explored in literature,[11],[12],[13] and researchers[14] have recently been putting effort into creating useful methods for classifying interarch relationship in such patients.

The need for yardsticks that would take account of the morphological specifics of BCLP stimulated, on the last decade, the creation and refinement of the Bauru yardstick, which originally classified dental arch relationship in terms of sagittal, transverse, and vertical discrepancies in patients with BCLP.[15],[16],[17] At the beginning of the current decade, drawing on the advances in the method, Ozawa et al.[14] performed an extensive analysis on 776 sets of standardized plaster casts from 411 patients and developed a new concept of classification of occlusal discrepancies in patients with BCPL, the Bilateral yardstick.

Concerning its judgment criteria, the Bilateral yardstick regards the sagittal dental base relationship as the main feature and takes into account preexisting dental compensations. Aiming more precise application, the yardstick was subdivided into three, representing deciduous dentition (6 years old), early mixed dentition (9 years old), and early permanent dentition (12 years old), each one classifying the dental arch relationship in five possible scores, according to its severity [Figure 1], [Figure 2], [Figure 3].[14]
Figure 1: Representative models of the bilateral yardstick for 6 year-old

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Figure 2: Representative models of the bilateral yardstick for 9 year-old

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Figure 3: Representative models of the bilateral yardstick for 12 year-old

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As Goslon's and Atack's methods for UCLP, the Bilateral yardstick was originally conceived for the occlusal analysis of patients with cleft lip and palate through plaster dental casts,[4],[5],[14] but the rising demand for information exchange among rehabilitation centers across the world and innovations in technology have led researchers to experiment their employment on other occlusal records. For the UCLP yardsticks, the results concerning the reliability of their use on photographs and virtual casts were considered adequate,[18],[19],[20],[21],[22] despite some possible difficulties.[18],[23],[24],[25] In regard to the Bilateral yardstick, Leenarts et al.[27] already validated its use on photographs from a sample of 20 children with BCLP, but there is lack of evidence about its employment on virtual casts.

Within the scope of the research committed to the analysis of the validity of Bilateral yardstick in its different possible employments, this study aimed to verify the applicability and the reliability of this method on the evaluation of interarch relationship in patients with BCLP through three-dimensional (3D) virtual casts.


  Methods Top


Subjects

One hundred and twelve patients with BCLP were recruited in accordance with the ethical standards of the Brazilian national research committee and with the Helsinki Declaration to participate in this study. Individuals, who were all under the care of the same craniofacial anomalies rehabilitation center, were 81 (72%) males and 31 (28%) females, aged 6–12 years (mean 8.0, standard deviation [SD] 1.2), had no associated syndromes or malformations, were free from previous orthodontic treatment and from secondary autogenous bone grafting, had undergone primary cheiloplasty on a single turn at a mean age of 6.4 (SD 2.8) months and palatoplasty at 17 (SD 4.4) months.

Interarch relationship assessment

Plaster dental casts from all the 112 individuals were obtained, randomly numbered and scanned on a 3Shape R700 3D Scanner™ which scans the surface of each dental arch model with a laser beam, generating a 3D digital image that was processed with the 3Shape OrthoAnalyzer™. Upper and lower casts were first scanned separately and then on occluded position. The initial digital image produced was, then, cropped at the bottom of the vestibule so that virtual model bases could be digitally inserted and the final images generated [Figure 4]. The whole process took an average of 40 min per cast.
Figure 4: Virtual image obtained from a dental cast scanned in this study

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Three trained and calibrated orthodontists used the Bilateral yardstick to classify the interarch relationship on the 112 3D virtual casts produced, applying for each age group the proper criteria, as described by Ozawa et al.[14] Each rater performed the evaluation isolated from the others, in a properly arranged room, by examining the virtual casts through multimedia projection and scoring each case on a specific form produced for this purpose. A second round of evaluation was conducted under identical conditions 1 week after the first one.

Data analysis

Descriptive statistics were employed to describe the frequencies of the scores of the Bilateral yardstick on the studied sample. Weighted Kappa statistics (95% confidence interval [CI]) was calculated to determine intra- and inter-rater reliability of the yardstick when applied to 3D virtual casts.[14],[27],[28],[29] Strength of agreement was defined as poor (k < 0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and very good (0.81–1.00).[27]


  Results Top


Applicability of the yardstick and occlusal relationship

All the raters reported having experienced no difficulties in the employment of the Bilateral yardstick on 3D virtual casts, except for the one related with the evaluation of crossbites' severity, which was resolved during calibration, before the rating sessions. The method was considered simple and effective.

[Table 1] reports the frequencies of the scores of the Bilateral yardstick observed by each rater in both rounds. Good occlusal relationship or minor deviation (scores 1 + 2) was observed in 60 (53.6%) of the 112 patients evaluated. No more than 13 (11.6%) patients were classified as having a poor arch form (score 5).
Table 1: Number and percentage (in Parentheses) of patients classified in each score of the Bilateral yardstick per rater and round of evaluation

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Intra- and inter-rater reliability

[Table 2] reports the results of weighted Kappa statistics for intrarater agreement and [Table 3] reports the results of interrater agreement for the possible pairs of raters in each round of evaluation. All results indicated good-to-very good reliability of the yardstick when employed to 3D virtual casts.
Table 2: Intra-rater agreement: Weigthed Kappa, standard error and confidence interval (95%)

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Table 3: Inter-rater agreement: Weigthed Kappa, standard error and confidence interval (95%) per pairs of raters and round of evaluation

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  Discussion Top


This study aimed to verify the applicability and reliability of the Bilateral yardstick[14] on the evaluation of interarch relationship through 3D virtual casts. Therefore, 112 patients with BCLP were molded and had their plaster casts produced and scanned. The 3D virtual casts were classified by three trained orthodontists into two independent rounds of evaluations accordingly to the scores defined by the yardstick for each age group. Weighted Kappa statistics (95% CI) was calculated to determine intra- and inter-rater reliability.

The preponderance of male individuals on the studied sample is constant with the evidence that describes a higher prevalence of cleft lip and palate in this gender[31] and had also been observed by Bartzela et al.[31] on their longitudinal study of patients with BCLP from three rehabilitation centers. The mean ages of primary surgeries were also analogous to those depicted by these same authors[31] and remain within the range defined on the protocol of the center where the individuals are treated, considering that social and demographic issues had already been pointed out as possible determinants of variation in the age of primary cleft repair, particularly in developing countries.[6]

Occlusal yardsticks have been widely employed to assess interarch relationship in patients with UCLP, not only for clinical diagnosis but also for the evaluation of long-term outcomes of different treatment protocols.[20],[21],[32],[33],[34],[35] On the other hand, the assessment of occlusal condition in patients with BCLP still demands further investigation, despite the recent efforts.[14],[15],[16] Specially when one considers the morphological specifics of BCLP, such as maxillary deficiency, augmented lower anterior facial height generated by the clockwise rotation of the mandible and frequent anterior crossbite accompanied or not by open bite, which are well described.[37],[38],[39],[40],[41],[42],[43]

Originally conceived to be applied to plaster casts,[14],[15],[16],[31],[44] occlusal yardsticks have their use on photographs considered valid and reliable.[20],[26],[35] Advances in technology have turned 3D virtual casts more available for both clinicians and researchers. Along with other advantages, this sort of digital dental record can enhance the possibilities of knowledge interchange among centers by electronic data sharing and substantially reduce the need for storage space in comparison to plaster casts.[22],[32],[33],[34],[36] The employment of occlusal yardsticks on virtual casts is an innovation already validated for the analysis of interarch relationship in patients with UCLP,[20],[21],[35] but concerning BCLP, more evidence is still required.[13],[14],[20],[35],[43],[45]

In this study, raters considered the use of the Bilateral yardstick on the scoring of 3D virtual casts simple and effective. The only difficulty reported by them during calibration regarded the evaluation of crossbites' severity, which some authors[18],[23],[24],[25] already attributed to existing limitations on depth visualization in 3D images plotted on bidimensional screens. It must be highlighted that this issue requires particular attention during raters' training process since crossbite is the second major feature used for classifying interarch relationship in occlusal yardsticks designed for patients with cleft lip and palate.[18]

With respect to the results of the rating [Table 1], most of the individuals (53.6%) were classified as having good occlusal condition or minor deviation (scores 1 + 2), suggesting favorable prognoses of future interarch relationship outcome and orthodontic treatment. Score 3 was observed in a maximum of 18.8% of the patients, indicating edge-to-edge apical base relationship accompanied or not by crossbite, major deviations on dental arch form, especially on the upper arch, and uncertain prognoses. Score 4 was found at most in 22.3% of the individuals, pointing toward Class III apical base relationship, with maxillary deficiency, major deviation on arch form, and unfavorable prognoses. No more than 11.6% of the patients were rated as having extremely poor occlusal condition (score 5), characterized by Class III apical base relationship, with maxillary deficiency, crossbite, major deviation on arch form, and unfavorable prognoses indicative of orthognathic surgery.[14] Comparisons between these findings and the results of other surveys have been hampered by the lack of evidence concerning the assessment of interarch relationship in patients with BCLP through digital records. Therefore, further studies on this matter should be encouraged.

A first task to be carried out by those interested in evaluating the utility of a clinical-epidemiological yardstick is to assess its reproducibility, a property that is directly related with confidence that one can attribute to any health index.[3],[19] In this study, the reliability of the Bilateral yardstick on its employment to 3D virtual casts was analyzed by measuring intra- and inter-rater agreement through weighted Kappa statistics qualified by Landis and Koch's scale,[27] as done by Ozawa et al.[14] and Dogan et al.[20]

Results indicated very good intrarater [Table 2] and good-to-very good inter-rater agreement [Table 3] and are consistent with the existing evidence about virtual casts reliability on the assessment of interarch relationship of patients with cleft lip and palate, which describes weighted Kappa values for intrarater agreement between 0.62 and 0.87[21],[22] and interrater agreement between 0.64 and 0.78[22] on individuals with UCLP. Similar studies on individuals with BCLP are not available.


  Conclusion Top


Bilateral yardstick proved to be applicable to the assessment of dental arch relationship of patients with BCLP through 3D virtual casts, showing adequate reproducibility. The use of the yardstick was considered simple and effective by the raters. Good occlusal condition or minor deviation (scores 1 + 2) was observed in 53.6% of the individuals. Weighted kappa values indicated good intrarater and good-to-very good interrater agreement, supporting the reliability of this yardstick when employed to virtual casts. Further studies should be encouraged to face the actual lack of evidence in this field.

Acknowledgments

The authors would like to thank Dr. Gunvor Semb and Dr. Ross Long Jr. for the relevant intellectual contribution for the conception and the design of this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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