Original Article

The Cleft Palate-Craniofacial Journal

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A Retrospective Mixed Longitudinal Study ª 2020, American Cleft Palate-
Craniofacial Association

of Tooth Formation in Children With Clefts Article reuse guidelines:

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DOI: 10.1177/1055665620903186
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Sarah B. Kimbrough, DMD1 , William G. Parris, DDS, MS1,

Richard A. Williams, DDS, MS1, and Edward F. Harris, PhD1

Abstract
Objective: To test for systematic age changes in cleft children based on dental age.
Design: Retrospective case–control longitudinal study.
Setting: One orthodontic solo practice.
Patients: Nonsyndromic, complete cleft lip and palateCLP cases, either unilateral or bilateral (102 children; 370 radiographs),
between 4 and 16 years of age.
Interventions: Children were treated with a team approach, but only orthodontic radiographs were studied.
Main Outcome Measure: The principal outcome measure was dental age of the cleft cases compared to a sex-specific sample of
phenotypically normal children (1107 children), from the same geographical region. Multiple panoramic radiographs taken during
the course of orthodontic treatment were examined to track patterns of dental age as children matured. Analysis used linear
mixed models primarily testing for sex, cleft type (unilateral, bilateral), and hypodontia differences. Initial expectation was that
cleft children would exhibit delayed dental ages from postnatal stressors and would become more deviant with maturity.
Results: In childhood (4-6 years), both sexes were significantly delayed (P < .001), but dental age normalized around 8 to 10 years.
Boys experienced faster maturation thereafter than girls (P < .001). Only trivial differences occurred between unilateral CLP and
bilateral CLP samples.Hypodontia further depressed maturation rates (P < .001). Dental age improved in a decidedly curvilinear
fashion (P < .001), with greater change at earlier ages.
Conclusions: This report agrees with other contemporary studies, showing childhood catch-up. Older studies observed that
clefting caused significant delays that worsened with growth. This potential “seachange” suggests better recovery and quicker
normalization of children with clefts, perhaps due to improved management.

Keywords
dental maturation, dental age, environmental stress, age differences, critical period

Introduction Physiological age contrasts with the method of calendric

Biological (physiological) age is the concept that all children
progress from immaturity to maturity, but the rate or tempo can
differ from person to person (Tanner et al., 1975; Cole, 2012;
Cameron, 2015). A child’s tempo of maturity responds both to
intrinsic and environmental conditions. It is slowed by some
factors (eg, undernutrition, chronic disease, some genetic dis-
eases; Roberts et al., 1985; Hass et al., 2001; Hattab, 2013) and
quickened by other diseases (Lehtinen et al., 2000; Vuorimies
et al., 2017) and by “overnutrition” (Hilgers et al., 2006; Car-
neiro et al., 2017; Nicholas et al., 2018). Variability occurs
among children when a biological year is out of synch with a
calendar year. A principal use of biological age—gauged from
bone, teeth, or integument—is to evaluate the difference
between a child’s chronological and biological ages.
time, where children are born at age “0” and they advance en
bloc toward adulthood. Calendar age supposes that children
mature in lockstep, whereas a child’s biological age can follow
its own tempo, with ebbs and flows. All children progress from
immaturity to maturity, but the rate or “tempo” can vary, so a
1
Department of Orthodontics, College of Dentistry University of Tennessee,
The Health Sciences Center, Memphis, TN, USA
Corresponding Author:
Sarah B. Kimbrough, Department of Orthodontics, College of Dentistry
University of Tennessee, The Health Sciences Center, Memphis, TN 38163,
USA.
Email: sarahbkimbrough@gmail.com
2 The Cleft Palate-Craniofacial Journal XX(X)
“chronological year” need not equal a “maturational year”
(Boas, 1933; Demirjian, 1978; Cole, 2012).
Each tooth progresses seamlessly through cusp formation,
crown completion, and root development, advancing in its
degree of maturity as it does so. The tooth root begins to form
after the crown (enamel and dentin) have completed develop-
ment. The third type of tooth hard tissue, cementum, is secreted
by cementoblasts proliferating from the dental follicle
mesenchyme (Thesleff and Trummers, 2008).
The final stage, when the root apex closes around its neu-
rovascular bundle, marks complete maturity—a status that per-
sists throughout that tooth’s subsequent life. Age-progressive
changes do continue into adulthood (eg, secondary dentine,
root translucency, cementum accumulation), but the tooth’s
morphology is complete. Combined across teeth, staging yields
a child’s “dental age,” which is the age at which the average
child in the reference group achieved the observed degree of
dental development. This procedure works until about 16 years
when all teeth (except wisdom teeth) reach morphological
maturity.
A child’s dental age is not commonly the same as judged
from other tissue systems (such as handwrist bone age) because
different tissues respond to different growth axes (Demirjian
et al., 1985; Sukhia and Fida, 2010; Ró_zyło-Kalinowska et al.,
2011). Correlations between methods normally are positive,
but not particularly high (commonly r2 < 0.50), because of
different responsiveness.
Postnatal growth of children with nonsyndromic clefts is
slower than normal (Nyström and Ranta, 1988; Heidbüchel
et al., 2002; Heliövaara and Nystrom, 2009; Hazza’a et al.,
2009; Tan et al., 2012; Bindayel et al., 2014). There are many
causes for this, but a major factor is the postnatal
“environment” broadly defined. Children with clefts experi-
ence problems with feeding, respiration, speech, social inter-
actions, and many other physical and psychosocial problems
(Berkowitz, 2013; Losee et al., 2015). The permanent teeth
mineralize during this debilitating postnatal milieu (Kitamura,
1989), where several environmental stressors slow growth (eg,
feeding problems, airway problems, aspiration problems,
recurrent surgeries, etc).
The focus of this study was on quantifying the degree of
difference between children with clefts vis-à-vis comparable
noncleft norms. This has been studied before, notably the series
of papers by Ranta (Nyström and Ranta, 1988; Nyström et al.,
1988; Ranta, 1984, 1986; Pöyry et al., 1989), but traditional
prior studies have been cross-sectional—children with clefts
were studied just once. The present study monitored the dental
formation of children with clefts across time. This was done
retrospectively, using panoramic radiographs taken periodi-
cally for clinical purposes.
Pöyry et al. (1989) compared children with clefts in 2 age
groups (3-9 and 8-14 years). The younger group had a dental
delay of 0.5 years, and this diminished to 0.2 years in the teen-
age group. However, these 2 groups consisted of different indi-
viduals, so there is no guarantee that 1 sample transitioned into
the other. Others (Heidbüchel et al., 2002; Tan et al., 2017)
have followed children longitudinally, finding an improvement
in dental maturation with age (ie, a catch-up or compensatory
response).
Materials and Methods
Prior institutional review board approval was granted (IRB
#18-06094-XP), and the study examined anonymized panora-
mic radiographs from 1 solo orthodontic practice that focuses
on the treatment of children with craniofacial anomalies. The
sample consisted of 102 nonsyndromic cases with complete
CLP (72 boys; 30 girls): 70 with unilateral clefts (51 boys,
19 girls) and 32 bilateral clefts (21 boys, 11 girls). All cases
were American whites by self-assessment (Edgar et al., 2011).
Dental mineralization of the lower left permanent teeth
(Figure 1) was scored using the grading scheme of Demirjian
et al. (1973). All panoramic radiographs (n ¼ 370 films) taken
between the chronological ages of 4 and 16 years were studied.
No radiographs were less than a year apart. The highest stage
actually attained was recorded, without interpolation (Dahlberg
and Menegaz-Bock, 1958). All teeth were independently
scored twice by the senior author with sessions over 2 months
apart. The few inconsistencies were resolved through rescoring
and consensus with the other authors.
Interobserver reliability was gauged by a second author
scoring teeth on 40 films selected at random across the span
of ages (280 teeth). The intraclass correlation (supposing a 2-
way random effects model) was high, at r ¼ 0.987. This strong
concordance argues against the improbable chance that the
original scorer was biased. It also supports the clarity of Demir-
jian’s grades and criteria.
A 15-year cohort was sampled. Birthdates were between
1996 and 2010, and all nonsyndromic cleft cases from the
practice meeting inclusion criteria were included. The intent
was to record the consequences of contemporary treatment
rather than older approaches. Treatment varied by individual’s
needs, but the general orthodontic protocol was (1) presurgical
nasal molding in infancy (Massie et al., 2018), (2) lip repair at 3
to 4 months, (3) palate repair at 12 months, (4) orthodontic
treatment in the mixed dentition, including arch expansion and
reverse pull facemask headgear in preparation for bone graft-
ing, and (5) comprehensive orthodontics in the permanent den-
tition including additional arch expansion, headgear treatment,
or orthognathic surgery as needed.
Each grade in the Demirjian system (Figure 1) has a stan-
dard deviation close to 0.3 years (Liversidge, 2011). Prospec-
tively, a power analysis was computed (Faul et al., 2007)
assuming a 1-sample difference of at least 1 grade (with a ¼
.05 and b ¼ 80%). This indicated a need for sample size of 30
patients per grade. This estimate was doubled to accommodate
sex-specific tests. In actuality, we chose to examine all cases in
the orthodontic office that met the inclusion criteria, and this
exceeded the limit of 70 patients at each grade. A total of 102
patients was studied (ie, the complete available sample meeting
selection criteria), with multiple films per individual. Cases and
controls were not matched. The sample of phenotypically
Kimbrough et al 3

Figure 1. Schematic drawings of the 8 ordinal stages per tooth type developed by Demirjian et al. (1973). The visually assessed ordinal stages
(A!H) are labeled with letters. Grades not illustrated occur at very young ages never encountered in this study. The Demirjian paper includes
photos and detailed written descriptions of each stage. Dashed lines in root areas mark the bony vacuolization that precedes tooth formation.
The lines within the tooth crowns denote the coronal limits of the formative dental pulp.

normal children (n ¼ 1100) was treated as the population stan-
dard, and the cleft cases were compared to it. That is, dental
ages of the children with clefts were compared, by sex, to
normal noncleft American white children living in the same
region of the country and the same range of birthdates (EF
Harris, 2019). Each radiograph of the children with clefts was
studied to (A) identify the stage of each tooth in the lower-left
quadrant (1 of 8 stages), then (B) the z-score was calculated for
that tooth-stage-sex. This converted tooth mineralization stages
to standard deviations (years) between that CLP case and the
normative data. Transformation harmonizes data to the same
units. The z-score formula was
ðCA norm  CA cleft Þ
z¼
sd norm
In words, the chronological age at the patient’s film was
subtracted from the normative age at that stage, and this
difference was divided by the normative group’s standard
deviation. Positive z-scores indicate that the cleft case was
developmentally advanced relative to the normative data;
negative values showed the cleft case was less mature. Z-
scores were calculated for each of the 7 lower left teeth.
To provide a composite measure for each child’s examina-
tion, the mean of the 7 tooth-specific z-scores was
averaged.
Each patient’s chronological age at each radiograph was
assigned to a 2-year age interval (4-6, 6-8, 8-10, 10-12, and
14-16 years) with just 1 X-ray per interval. This step is unne-
cessary, but it helps interpretation and permits “age interval” to
be cast as a fixed effect.
Since hypodontia is elevated in cleft cases (De Stefani et al.,
2019) and because hypodontia slows dental development
(Dhamo et al., 2016), the number of congenitally missing per-
manent teeth (ignoring maxillary lateral incisors in the cleft
proper and third molars) was used as a covariate in the statis-
tical analysis. Hypodontia was categorized into 3 grades: none
(all 26 teeth present), slight (1-2 teeth), and more (3þ teeth).
Analysis used linear mixed model (LMM) analysis (Ver-
beke and Molenberghs, 2001; Singer and Willett, 2003). Two
fixed predictors were sex (boy and girl) and type of cleft (uni-
lateral, bilateral). “Cases” were a random effect, and the out-
come variable was tooth mineralization z-score (years).
Repeated measures were the series of radiographic examina-
tions taken for each patient, and the number of films and ages
varied based on clinical needs. With LMMs, fixed effects are
interpreted in the usual analysis of variance fashion, but the
random effects are variances—distributions of ages around
which an event was distributed—so interpretation can be off-
putting to researchers accustomed to dealing with variance
ratios.
4 The Cleft Palate-Craniofacial Journal XX(X)

Figure 2. A, Plot of average z-score across the mandibular permanent 7 left teeth (sexes combined). A cubic polynomial was fit to the data to
emphasize the nonlinear change in scores across time. B, Plot of z-scores, by tooth, against age interval, treating the data cross-sectionally.
Splines connect the means. The principal observation is that tooth formation was delayed at the early age interval, but, by roughly 10 years of age,
compensatory growth had accelerated maturation to that of the normative standards. Tooth abbreviations are central incisor (I1), lateral incisor
(I2), canine (C), first premolar (P1), second premolar (P2), first molar (M1), and second molar (M2).

Two cardinal issues were (1) whether dental age of the
sample with clefts matured at different rates than nonclefts and
(2) whether the difference between dental age minus chrono-
logical age (DA  CA) changed over age. Preliminary testing
indicated that random intercept and random slopes contributed
significantly to explained variation. That is, each case was
permitted to have its own starting point (intercept) and proceed
at his/her own pace (slope). A quadratic term (age2) and a cubic
term (age3) were used in the models as fixed effects to accom-
modate curvilinear change in dental maturity with child’s age.
Variance composition can be altered within an LMM, but
Akaike information criteria (West et al., 2014) indicated that
a “heterogenous first-order autoregressive” covariance struc-
ture was the preferred fit. This means the data (formation stages
among a person’s radiographs) were correlated, but depen-
dency degraded with increasing time (age) between radio-
graphs. Tests were 2 tail, and statistical significance was
evaluated at a ¼ .05.
Results
As a preliminary view (Figure 2), data were plotted by sex and
age interval, but these figures combine examinations of multi-
ple ages for the children, thus ignoring statistical dependencies
among tooth stages within the same child. Still, these approx-
imate results suggest avenues of exploration (Figure 2), notably
(1) upward slopes of the scores of each tooth with age. Z-scores
were negative at the younger chronological ages, indicating
these children with clefts were maturing more slowly than
controls. However, with advancing age, z-scores of these same
children advanced closer to a z-score of 0. (2) Girls appeared to
possess smaller (less deviant) z-scores than boys, particularly at
the older age intervals (Figure 3), but any difference between
unilateral and bilateral cases was indeterminant. (3) Different
children appeared to mature at different tempos. Some showed
little retardation relative to noncleft controls. Others developed
very slowly. This variability suggests that different growth
trajectories (slopes) should be incorporated. (4) There were
several missing data. Indeed, no patient had a radiograph at
each of the 7 age intervals. For these several reasons, conven-
tional analysis of variance statistics would do a poor job of
representing these data (Singer and Willett, 2003).
Results of the LMM analysis show several statistically sig-
nificant differences (Table 1) among the 7 teeth because teeth
mineralize at different ages. For example, incisors have almost
completed formation at the earliest age interval (4-6 years),
while a fuller picture is available for the canine, premolars, and
second molar. Consequently—and because the individual teeth
exhibit redundant patterns (Figure 3)—results of the “averaged”
or composite measure are emphasized here. Moreover, tooth
formation tempos are intercorrelated (Moorrees and Kent, 1981).
All intercepts were significantly less than 0. Indeed, the F
ratios associated with the intercepts were the largest encoun-
tered. The exception was the lower central incisor, which is the
first tooth to mineralize (Kitamura, 1989), so this tooth seems
to have largely escaped the debilitating effects of infancy. The
other teeth show that, as newborn, the children with clefts
exhibited significantly delayed dental ages. However, this
assumes a linear trajectory of maturation, which is known to
be false, and since examinations did not begin until 4 years of
age, true intercepts at the origin (conception) are very poorly
extrapolated by these postnatal data. The most that can be said
is that dental age significantly improved relative to calendar
age as time went on.
The principal finding was the upward slopes of the scores of
each tooth (Table 1). Mean z-scores changed significantly (nor-
malized) as the children grew. This “catch-up” is evident in the
mixed model (Table 1) as the significant linear effect, but,
notably, also by a significant quadratic term (age2) as the
quickened rate of maturation temporizes and there was a sub-
sequent plateauing (cubic term, age3) once the child’s target
growth rate supposedly has been reached.
Kimbrough et al 5

Figure 3. Plots of mean z-score by age grade and sex. The last graph (labeled “Ave”) is the average z-scores for the 7 individual teeth. Girls’ data
were coded as round symbols; boys as squares. C, canine; I1, central incisor; I2, lateral incisor; M1, first molar; M2, second molar, P1, first
premolar; P2, second premolar, and average of all 7 teeth (“Ave”). Error bars are not shown since they are biased because formation status
among age grades are intercorrelated within individuals.

The “sex” difference reported by several studies (Nolla, scores than boys. This sex difference in how children were
1960; Moorrees et al., 1963; Demirjian et al., 1973) was affected by the cleft also increased over time. It was not
statistically significant, with girls having less severe z- detectable for early-forming teeth (incisors, first molar) but
6 The Cleft Palate-Craniofacial Journal XX(X)

Table 1. Results of Linear Mixed Models Analyzing 7 Permanent Mandibular Teeth and a Composite Measure of Dental Maturity.a

I1 I2 C P1 P2 M1 M2 Mean Z

Dependent F P F P F P F P F P F P F P F P
Intercept 0.0 .990 13 .001 57 .000 512 .000 232 .000 146 .000 166 .000 49 .000
Sex 0.0 .990 0.0 .952 0.7 .392 5.8 .030 7.1 .010 0.8 .385 11.8 .001 8.2 .005
Cleft type 2.6 1.000 1.5 .231 7.0 .010 0.2 .644 0.0 .986 0.0 .972 0.1 .816 0.7 .392
Sex  cleft type 1.0 1.000 1.0 .332 2.2 .139 0.5 .497 0.0 .983 0.0 .947 0.4 .552 0.6 .445
Age2 4.4 .047 9.8 .006 0.6 .445 106.5 .000 67.1 .000 43.7 .000 129.0 .000 53.2 .000
Age3 0.8 .369 2.8 .109 0.5 .500 88.0 .000 56.1 .000 9.6 .013 98.6 .000 42.3 .000
Hypodontia 0.1 .731 0.2 .667 8.0 .007 3.0 .085 5.3 .024 0.0 .997 16.2 .000 9.5 .003

Abbreviations: C, canine; F, F ratio; I1, central incisor; I2, lateral incisor; M1, first molar; M2, second molar; P1, first premolar; P2, second premolar; P, P value.
a
“Mean z” was the average z-score of the 7 teeth and is used as a summary index of the sample’s dental status. Each tooth was a separate analysis, and results
depended on how many stages were represented at the examinations. Probabilities were 2 tailed. P values significant at .05 or less are given in italics .

Figure 4. A, Plot of the distribution of hypodontia by number of congenitally missing teeth (third molars omitted). There were 163 missing
teeth in 102 cleft cases; percentages are shown above the bars. B, Range of missing teeth was categorized into 3 grades (none, 1-2 teeth, and 3þ
teeth). *In B, missing upper lateral incisors were omitted.

became apparent with the later-forming teeth, like the sec-
ond molar.
Hypodontia had a further delaying effect on dental age
(Table 1). Hypodontia ranged from 0 to 7 teeth in this series
(Figure 4). Hypodontia significantly depressed dental age for
C, P2, M2, and the averaged summary. This agrees with prior
research (Ranta, 1982; Eerens et al., 2001; Dhamo et al., 2016)
and others, although Eerens et al. (2001) results were
nonsignificant.
There was scant evidence that children with bilateral clefts
developed differently than those with unilateral clefts. Just the
canine showed a significant effect, with bilateral cases being
more delayed at the 4 to 6 age interval (Figure 5), and the
composite measure had indistinguishable z-scores between uni-
lateral and bilateral clefts (P ¼ .392).
It was unexpected to see a “catch-up” in dental maturation
(Figure 3). For example, Ranta (1986) reviewed the older lit-
erature and concluded that dental delay was “more severe in the
older age group than in the younger age group” with isolated
CLP. Striking differences were found in the present compari-
sons; maturation improved rather than worsened with age. Girls
moved close to z ¼ 0 (normal maturation), while boys signif-
icantly exceeded z ¼ 0 and matured faster than anticipated
during the older age intervals (>8-10 years).
Figure 3 also makes the point that change across ages was
curvilinear. This altered velocity was accommodated in the
present models by including quadratic (age2) and cubic (age3)
terms. Expectation (Figure 6) was that the linear effect tested
for change in z-score across age intervals, while age2 evaluated
whether the rate of change altered across time, and age3 tested
for a plateau as z-scores normalized near 0. Results (Table 1)
show that age2 was significant for teeth that formed by late
childhood. Incisors mineralized prior to the interval of normal-
ization. Age3 was statistically significant for those teeth, nota-
bly the canine and second molar, that completely mineralized
during the older age intervals.
Discussion
Prior studies often found that children with clefts were devel-
opmentally delayed (Nyström and Ranta, 1988; Heidbüchel
et al., 2002; Hazza’a et al., 2009; Heliövaara and Nystrom,
2009; Tan et al., 2012; Bindayel et al., 2014) and that bilateral
clefts were more delayed on average than unilateral samples.
Studies of dental maturation measure how children are inter-
acting with their environment (defined broadly), so less refined
and less comprehensive treatment protocols should impact
growth more dramatically. Parenthetically, we appreciate that
Kimbrough et al
Figure 5. Plot of canine z-scores across age intervals. This was the
only tooth to exhibit a significant difference between cleft types. Z-
scores were lower in the bilateral clefts (adjusted for sex), but neither
group (univariate or bilateral) differed significantly from 0 except at
the 4- to 6-year examination.
Figure 6. Hypothetical pattern of change in z-score with age occur-
ring in the present data. Z-scores were strongly negative at early ages,
but the subsequent slope diminished with age, such that dental
maturation was not statistically different from noncleft controls by late
childhood.
there may be unidentified genetic predispositions to clefting
(Thieme and Ludwig, 2017; Gu et al., 2018), but we choose
to emphasize environmental responses—which can be altered
by earlier and less-invasive treatments. Children with clefts
have been labeled “weakly buffered” (Bailit et al., 1968;
Sofaer, 1979; Ranta, 1986).
It is confirmatory that the 7 individual teeth showed consis-
tent changes across time. Teeth within an individual are inter-
correlated, not only regarding size (Harris and Bailit, 1988) but
also formation and eruption (Moorrees and Kent, 1981). Also,
teeth develop using similar, repetitive biochemical signaling
(Jernvall and Thesleff, 2000; Kangas et al., 2004; Tummers
and Thesleff, 2009). A benefit of examining multiple teeth is
to obtain a longer record of how the child was coping with his/
her environment than afforded by any single tooth. Some teeth
seem to be more informative than others (Figure 3), but this
involves the ages at formation relative to the ages at the exam-
ination. So, as an example, most of the incisors’ formation
occurred earlier than recorded by the radiographic record. Best
represented were the canine and premolars since their forma-
tion coincided with treatment ages.
If children are followed long enough, they all will attain
biological maturity. Typically, children reach complete tooth
mineralization around 16 years of age, ignoring the late-
forming and highly variable third molars (Moorrees et al.,
7
1963; Demirjian et al., 1973). Here, these children with clefts
were “normalized” with regard to tooth formation much earlier
than if duration of examination simply were protracted. By 8 to
10 years of age, dental maturity was statistically indistinguish-
able from noncleft norms. We emphasize that results apply to
“these children” because we suspect that those in historically
different times and/or with different access to cleft care may
not have done as well. Prahl-Andersen (1976) may well have
been the first to document this compensatory improvement in
later childhood, and others have confirmed this trend (Heidbü-
chel et al., 2002; Huyskens et al., 2006; Tan et al., 2017).
Reasons for the catch-up in dental maturity are not clear, but
its recognition accounts for some of the variability among
studies—depressed dental development is significant early on
but typically ameliorates with advancing age.
Girls normally have faster dental maturity tempos than boys
(Garn et al., 1958; Nolla, 1960; Moorrees et al., 1963) and this
female-precedence likewise occurs in children with clefts. Fig-
ure 3 also shows that girls with clefts are less affected than boys
with clefts—which is a common sex difference (Stinson, 1985)
but without an obvious explanation.
Clinical implications of these results revolve on recogni-
tion of the delayed growth in infancy and childhood. We
assume that tooth formation observed here is just 1 indicator
that the child with a cleft can be developmentally delayed (eg,
Bardach, 1990; Berkovitz et al., 2009). This is by no means
new information, but since health-care workers treat individ-
ual children and not some abstract norm, these results reaffirm
that treatment generally may be delayed (and perhaps length-
ened) relative to noncleft cases for early procedures. It is
fortuitous that the significant delay seen in the children with
clefts significantly ameliorated over time. For the majority of
the sample, treatment after about 10 years of age should pro-
ceed normally. For example, the modal age for definitive
orthodontic treatment is around 12 years of age, once all
permanent teeth (excluding wisdom teeth) have erupted. The
present study suggests that children with clefts can be
expected to respond normally as regard to development,
though there may be anatomical issues specific to the cleft
(Böhn, 1963; Ranta, 1982).
A limitation of this study was that only a single geographic
location—and 1 orthodontist—was sampled. Results would be
more generalizable if multiple clinicians had been included.
Likewise, cases were all were American whites. And, we
depended on an orthodontist’s radiographs, which seldom are
taken until indicated for tooth alignment once most permanent
teeth are present. Earlier treatment, such as nasal molding,
rarely requires radiographic examination. More encompassing
records (perhaps by adding surgeons’ records) would provide a
more complete growth record. It would be interesting, for
example, whether tooth formation is delayed at birth and how
slowed dental maturation becomes in infancy prior to the
observed catch-up in late childhood.
Development of children with facial clefts has been studied
extensively, and several researchers report slowed tempos of
bone development (Bowers, 2011; Batwa et al., 2018), and
8 The Cleft Palate-Craniofacial Journal XX(X)
dental maturation is delayed (Ranta, 1986; Mitsea and Spyro-
poulos, 2001), as well as somatic growth (Drillien et al., 1966;
Ranalli and Mazaheri, 1975). Moreover, tooth size is dimin-
ished (Sofaer, 1979; Antonarakis et al., 2013) because enamel
and dentin have virtually no reparative ability, so they forever
reflect their environment during formation. Since teeth rarely
begin to erupt without substantial root development (Grøn,
1962), tooth emergence also tends to be delayed in children
with clefts (de Carvalho et al., 2004; Kobayashi et al., 2010)
and the crown–root ratio can be impaired (Al-Jamal et al.
2010), along with other dental anomalies (Nicholls, 2016; Sá
et al., 2016).
Conclusion
This retrospective mixed longitudinal study examined dental
mineralization in children with clefts (n ¼ 102) using LMMs.
The study confirmed that the sample with clefts was signifi-
cantly delayed as young children, but the same children became
normalized in a curvilinear fashion by 8 to 10 years of age.
Females, as a group, fared significantly better than boys, but
little difference distinguished unilateral and bilateral clefts.
Hypodontia further slowed dental maturation.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Sarah B. Kimbrough, DMD https://orcid.org/0000-0001-
9642-9917
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