Maxillary Anterior Tooth Size and Arch Dimensions in Unilateral Cleft Lip and Palate

Benjamin R.K. Lewis, B.D.S., M.Clin.Dent., M.Orth.R.C.S. (Eng.), Melanie R. Stern, B.D.S., M.Orth.R.C.S. (Eng.), F.D.S.R.C.S. (Eng.), Derrick R. Willmot, B.D.S., M.Orth.R.C.S. (Eng.), F.D.S.R.C.S. (Eng.)
Objective: To investigate differences in size of the maxillary permanent anterior teeth and arch dimensions between individuals with repaired unilateral cleft lip and palate (UCLP) and a matched control group representing the general population. Design: Retrospective study cast review. Participants: Study casts of 30 subjects due to commence orthodontic treatment following an alveolar bone graft (ABG) were collected from the Cleft Lip and Palate Units in South Yorkshire. Thirty control subjects were collected from a previously validated control group of white individuals in South Yorkshire. Main Outcome Measures: Casts were analyzed with an image analysis system to measure the dimensions of the maxillary permanent anterior teeth, incisor chord lengths, and the intercanine and intermolar widths. The results were analyzed statistically using paired t-tests and two-way univariate analysis of variance (ANOVA). Results: The mesiodistal widths of maxillary anterior teeth in the study group were smaller than the noncleft control group (p < .01). The dimensions of the cleft side maxillary incisors and incisor chord length were smaller (p < .05 and p < .01 respectively) compared with the noncleft side. The study group maxillary cleft side incisor chord length and maxillary intercanine width were narrower than the control group (p < .0001). Conclusions: (1) Anterior teeth are smaller mesiodistally in individuals with UCLP. (2) Maxillary incisors are smaller on the cleft side than the noncleft side. (3) UCLP subjects had smaller maxillary cleft side incisor chord lengths and intercanine widths than the control group despite pre-ABG expansion. KEY WORDS: arch dimensions, tooth size, unilateral cleft lip and palate

Variation in tooth size is influenced by genetic and environmental factors (Bailit, 1975). Some of the factors that contribute to this variability are race (Lavelle, 1972; Bishara et al., 1986, 1989), sex (Moorrees et al., 1957; Lavelle 1975; Al-Khateeb and Abu Alhaija, 2006; Haralabakis et al., 2006), hereditability (Alvesalo and Tigerstedt, 1974), and the presence of syndromes (Townsend, 1983; Peretz et al., 1996; Bell et al., 2001). It has been found that the teeth in men are uniformly larger than those in women, but not to a statistically significant level (Moorrees et al., 1957; Doris et al., 1981), and that there is no significant sexual dimorphism for
Dr. Lewis is Specialist Registrar in Orthodontics, Charles Clifford Dental Hospital, University of Sheffield, Sheffield, United Kingdom. Dr. Stern is Consultant Orthodontist, Charles Clifford Dental Hospital, University of Sheffield, Sheffield, United Kingdom. Prof. Willmot is Consultant Orthodontist, Charles Clifford Dental Hospital, University of Sheffield, Sheffield, United Kingdom. Submitted May 2007; Accepted December 2007. Address correspondence to: Professor Derrick Willmot, Orthodontic Department, Charles Clifford Dental Hospital, Wellesley Road, Sheffield, S10 2SZ, U.K. E-mail d.willmot@sheffield.ac.uk. DOI: 10.1597/07-078.1 639

tooth-size ratios (Nie and Lin, 1999). Although dental asymmetry is usually present, the differences between the left and right sides are small and of no clinical or statistical significance (Bishara et al., 1989). The literature reveals that, although there has been a substantial amount of research into variations in tooth morphology associated with cleft lip and palate (CLP), there are marked variations in the published results. The different approaches taken to perform the actual measurements of the study casts and techniques used to minimize random and systematic error may contribute to this variation. Foster and Lavelle (1971) reported that, in both the upper and lower jaws, the permanent teeth in patients with CLP generally had significantly smaller crowns than the noncleft control group, although the control values used in this study were found to be higher than the majority of those used by other authors (Moorrees, 1959; Alvesalo and Varrela, 1980; Peterka and Mullerova, 1983), and at variance with the control data included in one of the authors later papers (Lavelle, 1973). Peterka and Mullerovas (1983) investigation revealed no significant dimensional differences between mesiodistal widths of individuals with a cleft lip and palate and those without. However, only

640 Cleft PalateCraniofacial Journal, November 2008, Vol. 45 No. 6

the teeth in the right quadrant, or in the cleft cases, the noncleft side, were measured. Markovic and Djordjevic (1981) found that in the permanent dentition, the central and lateral incisors were significantly smaller in CLP, and that the canines, first/second premolars and first/second molars were smaller on the cleft side, but not to a statistically significant level. A number of studies have also investigated arch dimensions in cleft lip and palate. McCance et al. (1993) compared the study models of individuals with clefts of the secondary palate and a control group of noncleft individuals, using a reflex microscope. They found that there were significant differences in the tooth sizes, chord lengths, and arch widths, with the cleft group dimensions being generally smaller. In particular, they found that the teeth in the canine to incisor region were consistently smaller. They noted that there was no difference in the mean tooth widths between the left and right side in the cleft or the control groups. Athanasiou et al. (1988) investigated the dental arch dimensions in patients with unilateral left lip and palate (UCLP) and found that all the maxillary interdental widths and lengths were significantly smaller than the control group dimensions at all ages in childhood in the cases collected by Moorrees (1959), with the exception of the intermolar width at age 12 years. Blanco et al. (1989) looked at the maxillary dental arch in a group of CLP patients of both sexes over 12 years of age and compared them to a control group. They concluded that there was a significant reduction in all of the longitudinal arch dimensions and of the intercanine and intermolar widths in CLP patients. The impact on treatment of these potential differences between individuals with unilateral clefts and those without is a particularly under-investigated area. There have been many different reported techniques for the measurement of erupted teeth on study models. The traditional method is manual measurement with either calipers or dividers, which are considered the gold standard to which all other techniques are compared (Moorrees et al., 1957; Hunter and Priest, 1960; Bolton, 1962; Lavelle, 1970). Other methods which have been used to produce two dimensional linear measurements are stereophotogrammetry (Berkowitz, 1971), the Optocom (van der Linden et al., 1972; Moyers et al., 1976), optical profilometer (Kelly et al., 1977; Berkowitz et al., 1982), image analysis (Brook et al., 1983, 1986, 1998), reflex metrograph (Scott, 1981; Butcher and Stephens, 1982; Takada et al., 1983; Richmond, 1987), travelling microscope (Bhatia and Harrison, 1987), reflex microscopy (Speculand et al., 1988; Lowey, 1993), laser scanning (Soma et al, 1992; Kuroda et al., 1996), sonic digitization (Mok and Cooke, 1998), and 3D virtual model (Santoro et al., 2003; Zilberman et al., 2003). Following a review of the literature, it was decided that the most appropriate method for the measurement of dental dimensions on orthodontic dental casts of individuals with CLP and a control group representing the general

TABLE 1

Inclusion and Exclusion Criteria

Inclusion criteria Complete UCL P Consecutive subjects who had an ABG between April 1, 1983 and March 31, 1993 Had a repair of a complete unilateral cleft lip and palate White (because there are racial tooth size variations) Start of orthodontic treatment dental casts which are of good diagnosis quality Exclusion criteria Poor quality models Bilateral cleft lip and palate, incomplete cleft lip and palate Nonwhite Subjects who had not had an ABG prior to definitive orthodontic treatment Subjects with a known syndrome

population was computerized image analysis. Image analysis is the term used to describe the collective process of examining and evaluating an image using computer software and hardware. Image analysis has been shown to permit the accurate measurement of tooth dimensions with comparable or better reproducibility than the current gold standard of manual measurement (Brook et al., 1998). The use of a mounting jig with the image analysis system allows over 180u movement of the dental cast, and thus allows an image of the individual teeth to be taken down their long axis, no matter what their inclination or angulation. The process involves no direct contact of the points to be measured and therefore avoids risk of damage to the models, which in turn could affect repeatability and eliminates the potential problems of overestimating the dimensions producing a systematic error caused by using dividers or calipers to physically measure crowded teeth. The image analysis program allows sophisticated computer software to be used. This enables highlighted areas to be measured as well as the identification of their center, from which further point to point linear distances can be calculated. Images can be manipulated to improve contrast and therefore allow better landmark recognition, which in other techniques has been difficult. The center of a tooth can be calculated by the computer, from which intra-arch measurements such as intermolar and intercanine width, can be made. This method has been shown to be more reproducible than using identified landmarks, which have been shown to make reproducibility problematic. The aim of this investigation was to determine any differences in the size of the maxillary permanent anterior teeth and arch dimensions between individuals with repaired UCLP and a matched control group representing the general population. MATERIALS AND METHODS Study Group The study group comprised the study models of 30 individuals, 11 to 14 years of age, with UCLP who had

Lewis et al., MAXILLARY ANTERIOR TOOTH AND ARCH DIMENSIONS IN UCLP 641

FIGURE 2 Tooth dimensions to be measured.

FIGURE 1 Image capture experimental set up.

undergone alveolar bone grafting (ABG). Individuals who fulfilled the selection criteria (Table 1) were identified, in chronological sequence from the Sheffield Cleft Lip and Palate database and were compared with a control group of 30 randomly chosen white individuals from the general population of similar age range gathered from the same localities as the study group. This control group, who had not undergone any previous orthodontic appliance therapy, had previously been analyzed and validated, confirming it as a fair representation of the general population from the South Yorkshire region. The investigation was approved by the South Sheffield Research Ethics Committee (Research Proposal SSREC 04/ Q2305/183). Method The study models were mounted on an adjustable jig, enabling 180u positioning. Photographs were taken of the maxillary dental arch and each of the permanent incisors and canines in plain view down the long axis, with a 32-bit digital camera using a 90-mm macro lens and 1.5 megapixel CCD producing 1012 3 1524 pixel images in a TIFF

format that was mounted on a vertical graduated stand. Illumination was standardized via white strip lights, with fluorescent daytime bulbs, mounted at 45u to the study models. Each image was calibrated using a 10-mm stainless steel scale placed at the correct depth of field and parallel to the lens of the camera (see Figure 1 for the image capture experimental set-up). The captured images were transferred to a desktop computer and viewed on a 17-inch 32-bit true color monitor. The images were processed using Adobe Photoshop (Version 4.0, Adobe Systems Inc., San Jose, CA) and analyzed with Image Pro Plus (Version 4.0, Media Cybernetics, Bethesda, MD) to provide linear measurements for the mesiodistal tooth widths and the intercanine, intermolar, and incisor chord lengths. A pilot study was conducted to test the experimental procedure and to gather sufficient data to provide a sample size calculation.

FIGURE 3 Arch dimensions to be measured.

642 Cleft PalateCraniofacial Journal, November 2008, Vol. 45 No. 6

TABLE 2 Distribution of Subjects With Unilateral Cleft Lip and Palate

Male Female Total

Left Right Total

13 9 22

4 4 8

17 13 30

Landmark Definitions The following measures were obtained (see Figures 2 and 3):

N Mesiodistal tooth widthsthe maximum linear distance

between the contact points or the points where the contacts would normally occur (Ballard, 1944; Moorrees et al., 1957; Bolton, 1962; Alvesalo and Tigerstedt, 1974; Axelsson and Kirveskari, 1983; Kieser et al., 1985). N Intercaninelinear distance between the central points of the canine teeth (Nelson et al., 2001) N Intermolarlinear distance between the central points of the first molar teeth (Nelson et al., 2001) N Incisor chord lengthsdistance between the anterior landmark (the average mesial contact point between the central incisors, Battagel, 1996) and the central point of the canine.

Statistical Analysis Sample size calculation was determined by an 80% power calculation utilizing a t test with p 5 .05. A paired Students t test was used to assess the differences between the cleft side and the noncleft side in the study group. A univariate analysis of variance (ANOVA) was used to assess differences between the study and control groups. A paired Students t test was used to assess systematic error (Altman, 1991). An interclass correlation coefficient was calculated to assess random error (Fleiss, 1981). Finally, limits of agreement were used to assess random error (Bland and Altman, 1986). RESULTS Statistical analysis determined that there was minimal systemic bias and an excellent level of reproducibility with
TABLE 3

intraclass correlation coefficients of ..99 for both the arch and tooth dimension measurements. There were 22 male and eight female subjects in the study group and 14 male and 16 female individuals in the control group. The cleft distribution is shown in Table 2, and the study and control dimensional means are displayed in Table 3. Statistical analysis confirmed that the permanent teeth and arch dimensions under investigation did not show any statistically significant differences between the sexes in both the control and study groups. This allowed the sexes to be combined, helping to minimize the problems associated with multiple testing. The mesiodistal tooth dimensions of the study sample were smaller than the control group. For example, the mean maxillary central incisor width was 8.39 mm on the cleft side, 8.86 mm on the noncleft side, and 9.33 mm in the control group. The arch dimensions recorded indicated that the mean intermolar widths were larger in the study group; whereas, the mean maxillary intercanine width and incisor chord lengths were smaller. Statistical analysis of the data was conducted using a Bonferroni correction to allow for the fact that multiple statistical tests were performed. The results are shown in Tables 4 and 5. Statistically significant differences were found between the maxillary central and lateral incisors and the maxillary incisor chord lengths of the cleft and noncleft sides. There was a general decrease in dental dimensions of the study group compared with the control, which was statistically significant. However, the maxillary intercanine width and maxillary cleft side incisor chord length were the only statistically significant arch dimension differences between the groups. DISCUSSION The study subjects were recruited retrospectively in chronological order from the Sheffield Cleft Lip and Palate Database. Although this ensured that a complete population sample was gathered, it also meant that there would not be an equal gender split because the incidence of UCLP is not the same in both sexes (Coupland and Coupland, 1988). In the study sample, there were 22 male to eight

Control and Study Groups: Maxillary Arch and Permanent Tooth Dimension Measurement Results
Study Group Control Group Cleft Side 95% CI* Mean (mm) SD (mm) 95% CI Mean (mm) Noncleft Side SD (mm) 95% CI

Dimension

Mean (mm)

SD (mm)

Intermolar width Intercanine width Incisor chord length Central incisor Lateral incisor Canine
* CI 5 confidence interval.

43.37 31.42 19.04 9.33 7.45 8.31

2.94 2.54 1.45 0.53 0.50 0.45

1.05 0.91 0.52 0.19 0.18 0.16

43.64 27.88 14.26 8.39 5.84 8.02

3.84 4.09 3.12 0.66 0.92 0.48

1.38 1.46 1.12 0.24 0.48 0.19

43.64 27.88 18.60 8.86 7.21 7.88

3.84 4.09 2.29 0.51 0.72 0.44

1.38 1.46 0.82 0.18 0.27 0.17

Lewis et al., MAXILLARY ANTERIOR TOOTH AND ARCH DIMENSIONS IN UCLP 643

TABLE 4

Mean Differences Between the Cleft Side and Noncleft Side Groups
Mean Cleft Side Group (mm) Mean Noncleft Side Group (mm) Difference Between Sides (mm) Level of Significance Corrected Level of Significance

Dimension Measured

Incisor chord length Central incisor Lateral incisor Canine

*p , .01; ** p , .05.

14.26 8.39 5.94 8.03

18.60 8.85 7.14 7.88

24.34 20.46 21.20 +0.15

p p p p

, 5 5 5

.0001 .0014 .0035 .0581

p p p p

, 5 5 5

.0001* .0112** .0280** .4648

female subjects for a male:female ratio of 2.75:1, whereas the left and right cleft ratio was 1.31:1, which, at first glance, may seem at odds with those previously published (Coupland and Coupland, 1988; Bellis and Wohlgemuth, 1999). This apparent difference can be explained by the relatively small sample sizes used in this study compared with the large number of participants who were involved in the previously mentioned epidemiological studies. The intercanine and intermolar width, along with the incisor chord lengths, were calculated using the center of the canine and first molar teeth rather than a particular landmark such as the cusp tip on the canine and the mesiobuccal cusp tip of the molar (Nelson et al., 2001). This was because the base of a canine or molar is larger than the occlusal surface, and any deviation in inclination or angulation would not affect the tooths footprint resulting in its location among the subjects being more consistent and reproducible, as demonstrated by a repeatability intraclass correlation coefficient for both the tooth and arch dimensions of .99. In this study, there were 30 study subjects and 30 controls. Previous research has been carried out on a varying number of participants (Foster and Lavelle, 1971; Sofaer, 1979; Peterka and Mullerova, 1983; Werner and Harris, 1989; McCance et al., 1993). The size of the study and control groups used in this investigation was statistically determined, by an 80% power calculation utilizing a Students t test with p 5 .05, to be sufficient to show any true difference in size between the two groups, deemed to be of clinical significance, set at 0.5 mm per tooth dimension, determined prior to the start of the investigation. In this study, 15 comparisons were made between the study and control groups. A Bonferroni correction was
TABLE 5

used to allow for the multiple comparisons (Altman, 1991). Previous published research on tooth size in CLP has not mentioned the problems associated with multiple testing and has not indicated that any corrections were performed on their results to accommodate the associated risk for increased type I (false positive) error. The results of this study are in agreement with Foster and Lavelle (1971) and Werner and Harris (1989), demonstrating that the mesiodistal anterior tooth size dimensions of the individuals with repaired UCLP were smaller, to a statistically significant level, than the control group. The only exception was the maxillary lateral incisor on the noncleft side, which was smaller, but not, in this study, to a statistically significant level. This may be explained by the fact that the maxillary lateral incisor has the highest degree of dimensional variability (Lysell and Myrberg, 1982). When the cleft and the noncleft sides were compared, the maxillary incisor chord length and the maxillary central and lateral incisor mesiodistal dimensions were smaller to a statistically significant level on the cleft side. This result is comparable to published data, with Rawashdeh and Bakir (2007) finding that in a Jordanian sample, the maxillary central and lateral were smaller on the cleft side, but only the lateral incisor was statistically significant. Sofaer (1979) and Werner and Harris (1989) also demonstrated statistically significant levels of asymmetry occurring between the cleft and noncleft sides. This could have implications in the clinical treatment of individuals with a repaired unilateral cleft lip and palate depending on the level of clinical significance of these differences. Statistical analysis reveals differences that are mathematically significant but may not be clinically significant.

Mean Differences Between the Dimensions of the Study Group and the Control Group
Mean Study Group (mm) Mean Control Group (mm) Difference Between Groups (mm) Level of Significance Corrected Level of Significance

Dimension Measured

Cleft side central incisor Noncleft side central incisor Cleft side lateral incisor Noncleft side lateral incisor Combined canine Cleft side incisor chord length Cleft side incisor chord length{ Noncleft side incisor chord length Intercanine width Intermolar width
{ Incisor chord length, excluding those with missing laterals. * p , .01; ** p , .05.

8.39 8.86 5.84 7.21 7.95 14.26 16.75 18.60 27.88 43.64

9.33 9.33 7.45 7.45 8.31 19.04 19.04 19.04 31.42 43.37

20.94 20.47 21.61 20.24 20.36 24.78 22.29 20.44 23.54 +0.27

p p p p p p p p p p

, 5 , 5 , , , 5 , 5

.0001 .0010 .0001 .2751 .0001 .0001 .0001 .2154 .0001 .6489

p , .0001* p 5 .0155** p , .0001* p 5 .0004* p , .0001* p , .0001* p , .0001* -

644 Cleft PalateCraniofacial Journal, November 2008, Vol. 45 No. 6

Differences that are clinically significant may not result in statistical significance because of insufficient power of the sample size (Freiman et al., 1978). In this study, the clinically significant dimensional difference between the groups was set at 0.5 mm per tooth at the start of the study. Only the maxillary central and lateral incisors on the cleft side reached this level of difference; although, the maxillary central incisor on the noncleft side was also over 0.4 mm smaller than the mean of the control group. The level of clinical difference is of great importance and should not be overshadowed by the statistical tests. Individual tooth dimensions are important in the clinical assessment of proportions and ratios. Orthodontists aim for an aesthetically pleasing dental and facial appearance with a good functional occlusion. To reach those clinical goals, the dentition has to be in proportion; this is important not only from an aesthetic standpoint but also occlusally (Bolton, 1958). This examination of the anterior teeth of individuals with repaired UCLP revealed that their mean dimensions were smaller than those of the control group representing the general population. If these teeth were universally smaller in a systematic way, then no serious complications would arise because, aesthetically, the teeth would all look in proportion and, occlusally, would articulate properly. This was not the case in our sample. The degree of difference between the tooth dimension means of the study and control groups varied from tooth type to tooth type. This could adversely affect the aesthetic and functional outcome of dental and orthodontic treatment, especially if not addressed in the original treatment plan. This study is in agreement with previous research (Foster and Lavelle, 1971; Werner and Harris, 1989; McCance et al., 1993) in finding that the anterior mesiodistal tooth dimensions of individuals with UCLP were smaller than those of a control group to a statistically significant level. This contrasts with the findings of Peterka and Mullerova (1983) who found no statistically significant difference. However, it must be pointed out that the cleft subjects in their study had measurements taken only from the noncleft side (which in this study, and that of Werner and Harris [1989], were found to be generally larger than cleft side in the maxilla) and could account for their findings. The asymmetry between the cleft and noncleft sides was found to be statistically and clinically significant for the maxillary central and lateral incisors but not for the maxillary canine. This is similar to the conclusions made by Werner and Harris (1989) with the exception that they also found the maxillary canine showed significant asymmetry. Peterka and Mullerova (1983) did cite in their investigation that there was a variation in the mesiodistal dimensional size of the control groups in the different previous studies, which had led to the mistaken belief that individuals with CLP had a dentition with smaller tooth dimensions. It is evident that the mean dimension values in both the study and control groups obtained in this study were generally larger (but

not to a statistically significant level) compared with values obtained through previous research. When interpreting the arch dimensions measurements obtained from the cleft study group, it must be remembered that these individuals have undergone secondary alveolar bone grafting. In preparation for surgery, individuals with oral clefts will often require a presurgical phase of orthodontics in an attempt to correct arch width discrepancies and to provide access for the bone graft to be placed. It would appear, from the literature, that no studies have investigated the short-term success of this orthodontic intervention. This could be because previous investigations have been performed on individuals before they have undergone alveolar bone grafting, thus, prior to any orthodontic expansion, or post definitive orthodontic treatment, when further arch expansion may have been performed. When the arch dimensions were examined, it was found that the only statistically significant difference in dimensions between the individuals with a repaired UCLP and the control group was the maxillary intercanine width and the incisor chord length on the cleft side. The arch dimension analyses indicate that, in this studys sample, by the time the individuals with CLP were ready for their definitive orthodontic treatment, the maxillary discrepancy in the intermolar width had been corrected but not the intercanine width discrepancy. The lack of maxillary intercanine width correction could be due to (1) inadequate prealveolar bone graft orthodontic expansion, (2) inadequate volume of bone placed during the alveolar bone graft, (3) inadequate post alveolar bone graft arch stabilization. Further research would be required to identify the cause of the inadequate intercanine width. An important aspect in the treatment of individuals with cleft lip and palate is the possible restorative management following the completion of their orthodontic treatment. The level of clinically significant dimension difference was set at 0.5 mm per tooth prior to the commencement of this investigation. Any tooth size discrepancy of up to 0.5 mm could possibly be corrected with enamel reduction alone, as long as the actual overall shape of the tooth in question did not require other forms of manipulation to improve aesthetics. Tooth size discrepancies can also be corrected by the enlargement of the diminutive teeth with the addition of restorative materials. When comparing the mean values for the cleft side and the noncleft side, it was shown that only the maxillary lateral incisor varied to a clinically significant degree with a difference of 1.37 mm. The maxillary central incisor was almost at the clinically significant level with a difference of 0.47 mm, and it must be remembered that these are the average differences, and that individual variation could be more marked. When the maxillary central incisor was examined at an individual level in the study group, it was found that 12 of the 30 (40%) subjects had a tooth size difference between the cleft and noncleft sides of over 0.5 mm. In this study sample, 53.3% had missing maxillary lateral incisors on the cleft

Lewis et al., MAXILLARY ANTERIOR TOOTH AND ARCH DIMENSIONS IN UCLP 645

side, while other studies have found an incidence of 30% (Kraus et al., 1966). CONCLUSIONS The following conclusions can be made from this investigation: (1) (2) The image analysis system used in this study showed an excellent level of reproducibility. The computer program used to identify the midpoint of a tooth using its perimeter was accurate and reproducible. The mesiodistal dimension of the maxillary permanent anterior teeth in the individuals with UCLP was significantly smaller than the control group representing the general population. The maxillary incisor chord length and the maxillary central and lateral incisor mesiodistal dimensions of the cleft and noncleft sides were significantly different in size, with the cleft side being smaller. With a clinically significant difference set at 0.5 mm per tooth, the maxillary central and lateral incisors on the cleft side had mean values that were smaller than the control group to a clinically important level. At the immediately predefinitive orthodontic stage, following the alveolar bone graft, this study sample had narrower maxillary intercanine widths and cleft side maxillary incisor chord lengths than the control group. At the immediately predefinitive orthodontic stage, following the alveolar bone graft, this study sample had maxillary intermolar widths and noncleft side incisor chord lengths that were not significantly different from the control group.

(3)

(4)

(5)

(6)

(7)

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