|Year : 2018 | Volume
| Issue : 1 | Page : 9-14
Morphological and dimensional characteristics of dental arch in children with beta thalassemia major
Disha Kumar, Anant Gopal Nigam, Nikhil Marwah, Puneet Goenka, Asmita Sharma
Department of Pediatric and Preventive Dentistry, Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan, India
|Date of Web Publication||28-Mar-2018|
Dr. Disha Kumar
C-603, Marvel Albero Near Khadi Machine Chowk, Kondhwa, Pune - 411 048, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: The aim of this study was to examine the arch dimensions of beta thalassemia major patients in comparison with normal individuals. Materials and Methods: Dental arch dimensions were compared between thalassemic patients and normal individuals in the age group of 12–16 years in the maxillary and mandibular arch corresponding to each other regarding age, sex and Angle's molar relationship. A total number of sixty cases in each group were taken. Maxillary and mandibular impressions were made with alginate for all the sixty participants in each group and poured with die stone. Measurement of inter incisor, inter canine, inter premolar and intermolar arch width, arch depth, right anterior, right posterior, left anterior, and left posterior arch length was carried out from each cast using digital Vernier caliper.Results: Unpaired t-test was used for comparison between the two groups. Statistically, a significant difference was found between the case and control groups in the maxillary arch in intercanine width, inter premolar width, intermolar width, right anterior arch length, right posterior arch length, and left anterior arch length. However, no statistically significant difference was found between the groups in inter incisor width, left posterior arch length, and arch depth in the maxillary arch. In the mandibular arch, statistically significant difference was found between the case and control groups in inter canine width, inter premolar width, inter molar width, and left anterior arch length. However, no statistically significant difference was found between the case and control groups in the mandibular arch in interincisor width, right anterior arch length, right posterior arch length, and left posterior arch length. Conclusion: Dental arch widths and arch lengths were significantly reduced in thalassemic patients as compared to normal individuals for the maxillary and mandibular arches.
Keywords: Arch dimension, arch length, arch width, thalassemia
|How to cite this article:|
Kumar D, Nigam AG, Marwah N, Goenka P, Sharma A. Morphological and dimensional characteristics of dental arch in children with beta thalassemia major. J Indian Soc Pedod Prev Dent 2018;36:9-14
|How to cite this URL:|
Kumar D, Nigam AG, Marwah N, Goenka P, Sharma A. Morphological and dimensional characteristics of dental arch in children with beta thalassemia major. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2018 Oct 16];36:9-14. Available from: http://www.jisppd.com/text.asp?2018/36/1/9/228744
| Introduction|| |
Thalassemia is a heterogeneous group of inherited blood disorders characterized by the deficient or absent synthesis of globin chains in hemoglobin, caused by defects in one or more genes responsible for producing the globin chains.
The homozygous type of β-thalassemia (also known as thalassemia major, Cooley's anemia, or Mediterranean anemia) exhibits the most severe clinical symptoms. Clinical symptoms present themselves at infancy between 6 and 24 months. Affected infants show growth retardation and become progressively pale. Children develop recurrent fever, feeding problems, diarrea, irritability, recurrent bouts of fever, and progressive hepatosplenomegaly may occur. Child becomes symptomatic when hemoglobin level drops to 3–5 g/dL when a child with thalassemia becomes symptomatic. Regular blood transfusions are needed to treat symptoms of hypoxia and to normalize hemoglobin level.,
The oral and facial manifestations are the result of extramedullary hematopoiesis that is due to the expansion of bone marrow. Protrusive premaxilla, bossing of the skull, saddle nose, and prominent molar eminences results in a facial appearance known as “chipmunk” face. Due to overdevelopment of the maxilla, a Class II skeletal base relationship is seen along with reduced posterior facial height, increased anterior facial proportions, flaring and spacing of maxillary teeth, increased overjet, and other types of malocclusion. Due to rotation of mandible and protrusion of maxilla, deep bite and anterior open bite occur more frequently.,,
Knowledge of dental arch dimensions such as arch width, depth, length, plays a key role in pedodontics. In diagnosis and treatment planning, the size and shape of dental arches will have implications in affecting space available, dental esthetics, and stability of dentition. Although β-thalassemia major is considered a public health problem, research in the literature pertaining to morphological and dimensional characteristics of the dental arch in affected patients is limited worldwide. Therefore, the aim of this study was to investigate dental arch parameters in β thalassemia major patients and to compare measurements with corresponding values in a group of unaffected participants.
| Materials and Methods|| |
The aim of the present study was to compare key dental arch dimensions between thalassemic patients and control groups. The subjects in study and control group were selected such that they were corresponding to each other regarding age, sex, and Angle's molar relationship. Before the start of the study, ethical clearance for the study was obtained from Mahatma Gandhi University of Medical Sciences and Technology.
Source of data
The study group consisted of children who were affected only by β-thalassemia major. The study participants were taken from J. K. Lon hospital and South East Asia Institute of Thalassemia, in the city of Jaipur. All participants were on a regular blood transfusion regimen and were having hemoglobin levels between 6 and 10 g/dL. They were being given an iron chelating agent (desferrioxamine, 35–50 mg/kg) to control iron overloading and folic acid supplements. The control group consisted of participants who were attending the outpatient Department of Pedodontics and Preventive Dentistry, Mahatma Gandhi Dental College and Hospital, Jaipur. Subjects in the age group of 12–16 years were selected. This age group was selected keeping in mind that no significant increase in arch width occurs after the age of 12 years.
Data collection method
- Intact permanent dentition
- Normal A-P relationship between the maxillary and mandibular molars, i.e., Angle's Class I molar relationship
- Absence of gross dental anomalies, crowding, and spacing
- No history of orthodontic treatment and prolonged nonnutritive sucking habit.
- History of allergy toward any dental material
- Clinically evident interproximal caries
- Any alteration in the number or shape of the teeth that might affect the diameter of the dental arch
- Any oral habit that might influence the dental arches
- Any hereditary or acquired dental or facial deformity
- Children with any systemic and local conditions not permitting the treatment
- Children with fractured teeth.
The children were examined after informing their parents about the study and obtaining written consent from them. Detailed dental and medical history was then obtained from the children as well as the parents. The impressions of the participants in the study group were made only after the scheduled transfusion. The impressions of the participants in control group were taken in the Department of Pedodontics and Preventive Dentistry, Mahatma Gandhi Dental College and Hospital, Jaipur.
The maxillary and mandibular impressions were made with alginate impression material (Improalgin, Dentsply) using suitably sized rim lock, perforated stainless steel trays, and the casts were immediately poured with die stone (Kalstone, Kalabhai). The casts were recovered from the impression immediately after the final setting time of the die stone, as specified by the manufacturer. Subsequently, the casts were trimmed and base was made with Plaster of Paris [Figure 1] and [Figure 2].
The dental arch dimensions of each cast were then carefully measured using digital vernier calliper till the nearest 0.01 mm of accuracy. The arch depth was measured using a brass wire. All the measurements were tabulated and recorded using Microsoft Excel [Figure 3], [Figure 4], [Figure 5], [Figure 6].
|Figure 3: Maxillary and mandibular rim lock perforated trays, alginate impression material, die stone, Plaster of Paris, rubber bowl, and spatula|
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The following measurements were conducted as follows:
- Arch width
- Inter incisor width – Inter-incisor width was measured from the distal contact point of the lateral incisor on one side to the distal contact point of the contralateral permanent lateral incisor
- Inter canine width – Inter-canine width was measured from the cusp tip of the permanent canine on one side to the cusp tip of the contralateral permanent canine
- Inter-premolar width – Inter-premolar width was measured from the tip of buccal cusp of the second premolar on one side to the buccal cusp tip of the contralateral permanent second premolar
- Intermolar width – Intermolar width was measured from the mesio buccal cusp tip of the first permanent molar on one side to the cusp tip of the contralateral second premolar.
- Arch depth
- Arch depth was measured as the shortest distance connecting the distal surface of the first permanent molar to the labial surface of the most anterior tooth in the arch [Figure 7].
|Figure 7: The upper arch showing the measurement of the anterior and posterior arch lengths|
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- Arch lengths
- Anterior arch length was measured between the mesial contact point of the permanent canine and distal contact point of the second premolar
- Posterior arch length was measured between the mesial contact point of the permanent canine and distal contact point of the second premolar [Figure 8].
|Figure 8: Measurement of inter-incisor, intercanine, inter-second premolar, and intermolar width and arch depth|
Click here to view
Medcalc 220.127.116.11 Version Software (MedCalc Software, Mariakerke, Belgium) was used for all statistical calculation. Continuous variables were summarized as mean and standard deviation whereas nominal/categorical variables as proportions. Continuous variables were analyzed using unpaired t- test whereas nominal/categorical variables were analyzed using Chi-square test. P < 0.05 was taken as statistically significant.
| Results|| |
Unpaired t-test was used for comparison between the two groups. Statistically significant difference was found between the case and control groups in the maxillary arch in intercanine width (P = 0.027), inter premolar width (P< 0.001), intermolar width (P = 0.002), right anterior arch length (P = 0.217), right posterior arch length (P = 0.050), and left anterior arch length (P = 0.045). However, no statistically significant difference was found between the groups in inter incisor width (P = 0.057), left posterior arch length (P = 0.074), and arch depth (P = 0.580) in the maxillary arch [Table 1].
|Table 1: Comparison of arch dimensions between cases and control group in the maxillary arch|
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In the mandibular arch, statistically significant difference was found between the case and control groups in intercanine width (P< 0.001), inter premolar width (P = 0.017), intermolar width (P = 0.017), and left anterior arch length (P< 0.001). However, no statistically significant difference was found between the case and control groups in the mandibular arch in inter-incisor width (P = 0.279), right anterior arch length (P< 0.001), right posterior arch length (P< 0.001), and left posterior arch length (P = 0.155) [Table 2].
|Table 2: Comparison of arch dimension between cases and control group in the mandibular arch|
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| Discussion|| |
This study looks into the morphogenetic changes in individuals suffering from thalassemia. The growth of thalassemic children generally is slow. Some exemptions are present, but they have abnormalities and problems in pubertal growth. The growth failure is due to various factors with most important being transfusion-related iron overload, chronic anemia, and chelation toxicity. The other factors that slow growth are zinc deficiency, growth hormone deficiency/insufficiency, psychosocial stress, and under nutrition. Tendency for retarded growth has been reported at the age of 8–10 years and as puberty approaches. A study by Saxena on Indian children with thalassemia shows the marked growth retardation after 9 years of age for girls and after 11 years age in boys. The author also observed that start of bone retardation was earlier than height and weight retardation and it increases with age. A study by Garn et al. found that the extent of dental development delay was around one-third of the skeletal delay. The study by Hazza'a on patients with thalassemia major indicate that the dental development get more delayed as the age increases.
The dental developmental delay and craniofacial manifestations will change the crucial landmarks that are seen in the maxillary and mandibular arch. The development of craniofacial deformities is dependent on factors such as patient age, degree of anemia, clinical symptoms duration, age at onset of transfusion therapy, and timing of splenectomy. The severity of thalassemia can be graded using the above-mentioned factors., Thalassemia major patients have narrower maxilla and shorter mandible as well as smaller incisive dental space in maxillary and mandibular arches. The environmental and genetic variation factors such as somatomedin deficiency and endocrine dysfunction cause delayed growth in thalassemic patient and it gets reflected on dental size. The thalassemic patients also have longer maxillary dental arch length due to anterior dental protrusion which increases overbite and overjet that causes lower lip getting trapped between upper and lower incisors which delays mandible growth. The change in first molar position, inclination, or buccolingual size of teeth leads to narrower widths in thalassemic patients.
The selection of 12–16 years age group was selected keeping in mind that there is no significant increase in arch width after 12 years of age. The evaluation of inter canine width in females and males by Graber and Swain showed marked increase in inter canine width during early mixed dentition period whereas there is no change beyond 12 years of age. Knott and Meredith (1966) observed the increase in width is greatest at the time of eruption of permanent incisors. Baume observed that the width impulse growth was strongest at the time of eruption of lateral incisors in mandible and central incisors in maxilla. The best time for the measurement of tooth size  is early permanent dentition as attrition is less and fewer teeth are extracted during this time.
The comparison of inter incisor, inter canine, interpremolar, and intermolar arch width between cases and control group in the maxillary arch showed decreased intercanine width, inter premolar width, and intermolar width in thalassemic patients whereas no significant difference was found in the inter-incisor width. In a similar study done by Hattab and Yassin, all the dental arch widths in thalassemic patients were found to be smaller as compared to control group, and the values were statistically significant. In a study done by Al-Wahadni et al., only the inter-incisor and intermolar widths were found to be less in children with thalassemia, and there was no significant difference between inter canine width and inter premolar width.
Comparison of the right anterior and posterior and left anterior and posterior arch length between thalassemic group and control group in the maxillary arch showed right anterior and posterior arch length as well as the left anterior arch length is less in thalassemic patients, but no difference is present in relation to the left posterior arch length. The study by Hattab and Yassin found similar results, the anterior arch length was less in study participants as compared to control groups but no statistically significant difference was found in the posterior arch length. Al-Wahadni et al. also found similar results with only difference being that in both the right and left posterior arch lengths, there was no significant difference between the thalassemic and control groups.
In this study the comparison of arch depth between the cases and control groups shows no statistically significant difference. This finding was contrary to the results found in the study by Hattab and Yassin  and Al-Wahadni et al. which showed statistically significant differences in arch depth of the maxilla (P< 0.001).
Comparison of inter incisor, inter canine, inter premolar, and intermolar arch width between cases and control groups in the mandibular arch shows that the mandibular arch width is less in thalassemic patients as compared to normal children except for inter incisor arch width. Hattab and Yassin  found similar results with the exception of inter incisor width which was found to be statistically significant between the two groups (P< 0.001). However, the study by Al-Wahadni et al. indicated no statistically significant differences between the study and control groups for canine widths and premolar widths of mandible.
Comparison of the right anterior, right posterior, left anterior, and left posterior arch length between cases and control group in the mandibular arch showed that only the left anterior arch length is less in patients with thalassemia as compared to control group in the mandibular arch. Studies done by Hattab and Yassin  as well as Al-Wahadni et al. show significant difference between anterior arch lengths but no significant difference between posterior arch lengths of the left and right side of dental arch between the thalassemic and control groups which is also not in agreement with this study.
The literature review showed limited studies on dental arch dimensions in thalassemic patients and the results of studies were not consistent. This is likely to be due different frequency of transfusion therapy in the patients. The craniofacial deformities were less in patients who took regular blood transfusion. The blood transfusion maintains the hemoglobin level (9–10 g/dl,) which suppress erythropoiesis to reduce skeletal deformities and extramedullary hematopoiesis. The study of inter molar arch width in 9–14 years age group by Anggraini et al. (2009) showed marked variation in intermolar width in all age groups. Thalassemic patients exhibited multifactorial delay in growth and development, but changes varied with each individual.
Changes in the size of dental arches in thalassemic patients have an impact on occlusal relationships. In this study, reduction in dental arch dimension in the study group was observed in comparison to control subjects. The knowledge of these changes is essential while planning orthodontic treatments. Hence, dentists should be mindful of the significantly reduced dental arch dimension seen in thalassemic patients. Proper diagnosis and careful treatment planning should be done in thalassemic patients keeping in mind the reduced arch dimensions and all the other manifestations associated with the disease.
| Conclusion|| |
Dental arch widths and arch lengths were significantly less in thalassemic patients as compared to normal individuals for the maxillary and mandibular arches. The knowledge of these changes is essential while planning orthodontic treatment. Proper diagnosis and careful treatment planning should be done in thalassemic patients keeping in mind the smaller arch dimensions and all the other manifestations associated with the disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Navneetha Krishnan S, Shagi G, Ravalya P, Nazia SK. Management of thalassemia. Int Res J Pharm 2013;4:1-3.
Galanello R, Origa R. Beta-thalassemia. Orphanet J Rare Dis 2010;5:11.
Vichinsky EP. Changing patterns of thalassemia worldwide. Ann N
Y Acad Sci 2005;1054:18-24.
Babu RH. Incisal and dental arch widths- Norms and ratios. Indian J Mednodent Allied Sci 2014;2:161-3.
Puri N, Pradhan KL, Chandna A, Sehgal V, Gupta R. Biometric study of tooth size in normal, crowded, and spaced permanent dentitions. Am J Orthod Dentofacial Orthop 2007;132:279.e7-14.
Hattab FN, Yassin OM. Dental arch dimensions in subjects with beta-thalassemia major. J Contemp Dent Pract 2011;12:429-33.
Saxena A. Growth retardation in thalassemia major patients. Int J Hum Genet 2003;3:237-46.
Garn SM, Lewis AB, Blizzard RM. Endocrine factors in dental development. J Dent Res 1965;44:243-58.
Hazza'a AM, Al-Jamal G. Dental development in subjects with thalassemia major. J Contemp Dent Pract 2006;7:63-70.
Logothetis J, Economidou J, Constantoulakis M, Augoustaki O, Loewenson RB, Bilek M, et al.
Cephalofacial deformities in thalassemia major (Cooley's anemia). A correlative study among 138 cases. Am J Dis Child 1971;121:300-6.
Phadke SR, Agarwal S. Phenotype score to grade the severity of thalassemia intermedia. Indian J Pediatr 2003;70:477-81.
Sripichai O, Makarasara W, Munkongdee T, Kumkhaek C, Nuchprayoon I, Chuansumrit A, et al.
Ascoring system for the classification of beta-thalassemia/Hb E disease severity. Am J Hematol 2008;83:482-4.
Anggraini N, Riyanti E, Padjadjaran EC. Description of upper intermoral dental arch size in thalassemia beta mayor aged 9-14 years old based on gender. J Dent 2009;21:61-5.
Graber TM, Swain BF. Current Orthodontic Principles and Practice. St Louis The CV Mosby Company: Missouri;1985.
Baume LJ. Physiological tooth migration and its significance for the development of occlusion; the biogenesis of accessional dentition. J Dent Res 1950;29:331-7.
Knott VB, Meredith HV. Statistics on eruption of the permanent dentition from serial data for North American white children. Angle Orthod 1966;36:68-79.
Al-Wahadni A, Alhaija EA, Al-Omari MA. Oral disease status of a sample of Jordanian people ages 10 to 28 with cleft lip and palate. Cleft Palate Craniofac J 2005;42:304-8.
Anggraini N, Riyanti E, Chemiawan E. Description of upper intermoral dental arch size in thalassemia beta mayor aged 9-14 years old based on gender. Padjadjaran J Dent 2009;21:61-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]