Assessment and Comparison of Temporomandibular Joint for Occurrence and Severity of Disorders in Adult Cases with Unilateral Cleft Lip and Palate and Non-cleft Class I: An Observational Study

Background: Cleft Lip and Palate (CLP) are hereditary deformity of craniofacial structure. Temporomandibular disorder has number of clinical problems affecting muscles of mastication and its associated structures. There are several methods used to evaluate temporomandibular dysfunction (MRI, etc), Helkimo index is a settler in advancing indices, other indices used are CMI, MFIQ, FONSECA. The design of the following study was to evaluate the TMJ disorders in UCLP, if any, and compare with the non-cleft cases. Methodology: Total 30 patients aged 16 to 20 years, will be selected from the patients coming to smile train Out Patient Department (OPD) of Orthodontics and Dentofacial Orthopaedics, Wardha. Study Protocol Kumar et al.; JPRI, 33(60B): 3240-3245, 2021; Article no.JPRI.80036 3241 The total cases will be divided into two groups: a) Group I unliteral cleft lip and palate cases b) Group II non cleft class I cases Digital records of the patient (lateral cephalogram, photograph, models) will be taken and stored. Helkimo, MFIQ, CMI, Fonseca will be recorded on all patients participated in study. The Helkimo index will be taken to assess the presence and severity and MFIQ index will be taken to assess mandibular functioning in cleft cases based on the questionnaire. Expected Results: The dental apparatus (interdental relation of maxillary and mandibular dentition) plays an important role in the temporomandibular joint's well-being. Trauma due to the occlusal instability has definite effect on the TMJ in long run. Cleft is always associated with inter jaw malocclusion and therefore TMDs in the cleft patient is thought to occur. The treatment protocol for grown cases with severe skeletal malocclusion is orthognathic surgery. The TMJ correction remains untouched. It can be expected that altered TMJ anatomy can lead to TMDs in cleft lip and palate cases. Conclusion: To convey the occurrence of TMDs in cleft due to the inter jaw malocclusion and its early treatment approach for TMJ deprogramming along with dental and surgical correction in CLP.


INTRODUCTION
Cleft lip and palate are the second most common congenital deformities of infants' craniofacial structure, which requires long-term functional and aesthetic rehabilitation. After the primary lip and palate surgery, the healed fibrous tissue leads to restriction of the growth of the maxilla in all 3 planes (vertical, sagittal and transverse), which leads to maxillary post displacement dysplasia [1].
The precedence of malocclusions in CLP patients is substantially high. Malocclusion basically occurs in the transverse plane; especially where the dental arches' adjourn symmetry can be clinically observed. They are also a prospective etiology of problems that are functional in nature, related to craniofacial structure. Hence, the patients with CLP are at risk of developing temporomandibular disorders due to mandibular disharmony. Temporomandibular disorder embraces a number of clinical problems affecting the muscles of mastication, the Temporomandibular joint (TMJ) and its associated structures [1,2].
Mandible is secondarily affected part of the craniofacial apparatus in cleft. The mandible and cranial base relationship is important as it influences both sagittal, vertical facial disharmonies. The position of glenoid fossa is most likely to play an important role in the establishment of different craniofacial patterns. The fossa is affected by change in mandibular condyle position. Mandible, which grows late based on the cephalocaudal growth gradients theory 3is always under the cranial base and maxilla confinement. But due to threedimensional constriction of maxilla, in the late growth spurt the mandible is gradually set free to grow forward downward depending on the altered growth and development of maxilla [3].
Contributing to the limited data on the effects of clefts on mandible. Few studies were performed in the department which evaluated and compared glenoid fossa morphology and depth in unilateral cleft lip and palate cases and the result suggested that, there was an increase in the depth and the width of the glenoid fossa and a decrease in the joint space, this may also influence the position of the articular disk [4][5][6][7].
In further studies, when the inclination of the condyle in the glenoid fossa was evaluated, it was found that, the altered inclination of the condyle results in a change in position of the articular disk which might further lead to the causation of TMD's in UCLPcases [2,5,6,8].
The study's limitation was that only the condyle and glenoid fossa were evaluated while disk position was not evaluated [8]. To evaluate TMJ dysfunction, various methods are used like tomogram and magnetic resonance imaging, but Helkimo is a pioneer in developing indices. Which record severity by clinical evaluated [4]. Helkimo index measure the severity and pain of TMJ disorders & consist of three types: Anamesis, clinical, occlusal dysfunction [2]. This index is excellent means to allow check disease severity, measure effectiveness of TMD but the only limitation is in anamesis type anaylsis there mild & severe anaylsis but moderate option and for overcoming this limitation. Craniomandibular index is introduced to measure objective severity of mandibular movements, joint noise and muscle & joint tenderness using clearly defined criteria, simple clinical methods and ease in scoring [2,5].
The dental apparatus and inter dental relation also play an important role in the occurrence of TMD in cases without any craniofacial anomaly [9]. The inter-arch dental malocclusion is also assumed to be a causative factor for TMD [3].
Meanwhile treating the CLP cases including orthopedic, orthodontic and orthognathic surgery [10,11]. The bite blocks used with the expansion devices act as TMJ deprogramming [10], can be expected to correct the TMD in the initial age, but this may not be true with all cases and these cases may show TMD in their later age to evaluate the occurrence of TMDs in the cleft [12][13][14][15].
This study aimed to evaluate the TMJ for disorders in UCLP, if any, and compared with the non-cleft cases.

Aim
To assess and comparison of temporomandibular joint for occurrence and severity of disorders in adult cases with unilateral cleft lip and palate and non-cleft Class I.

Hypothesis
Does the changed position of the mandible in craniofacial abnormalities like cleft deformities, the altered inclination of the condyle results in a change in position of the articular disk which might further lead to the causation of TMD's in Cleft lip and palate cases and Does crossbite due hypoplastic maxilla predispose to TMD in unilateral cleft patients.

Source of the Data
The subject to be studied will be selected from the smile train OPD and consent will be taken for the participation in the study, Department of Orthodontics, Sharad Pawar dental college, Sawangi.

Statistical Analysis
Sample size formula for difference between 2 means:

Study Design
In this analytical study, a total 30 patients (UCLP and non-cleft Class I), in age group of 16-20 years, will be selected.
The total cases will be divided into 2 groups: a) Group I -unliteral cleft lip and palate cases b) Group II -non cleft class I cases Digital records of the patient (lateral cephalogram, photograph, models) will be taken and stored. Helkimo, MFIQ indices, CMI index, and Fonseca index13 will be recorded on all cleft lip and palate patients. The Helkimo index will be taken to assess the presence and severity of TMD in cleft cases, while the MFIQ index will be taken to assess mandibular functioning in cleft cases based on the questionnaire and will be asked in their own language of understanding.

EXPECTED RESULTS
The dental apparatus (interdental relation of maxillary and mandibular dentition) plays an important role in the temporomandibular joint's well-being. Trauma due to the occlusal instability has definite effect on the TMJ in long run. Cleft is always associated with inter jaw malocclusion and therefore TMDs in the cleft patient is thought to occur. The treatment protocol for grown cases with severe skeletal malocclusion is orthognathic surgery. The TMJ correction remains untouched. It can be expected that altered TMJ anatomy can lead to TMDs in cleft lip and palate cases. cases. study consisted of 30 cases in the age group 9-12 year with 3 groups of PNAM, NON-PNAM, and NON-cleft cases. Evaluation of the condylar morphology revealed that the height and the length of the neck of condyle was the longest in Class I non cleft cases and shortest in UCLP non PNAM cases. At the same time, the anteroposterior and mediolateral condylar widths were widest in UCLP non PNAM cases and narrowest in Class I non cleft cases. When the dimensions of the glenoid fossa were evaluated, it was found that its depth and the height of the eminence of the glenoid fossa were deepest and longest in UCLP non PNAM cases than in Class I non cleft cases. It was also observed that the width of the glenoid fossa was widest in Class I non cleft cases and narrowest in UCLP non PNAM cases. On evaluating, it was found that the anterior, posterior, superior and medial joint spaces were highest in Class I non cleft cases and lowest in UCLP non PNAM cases. And it also showed that lateral joint space was the highest in UCLP non PNAM cases and lowest in Class I non cleft. Goslon score -4was found in 40% of study models of mixed dentition while Goslon score 2 and 3 each were found in 40% of study models in permanent dentition. Significant correlation was found between Goslon score and skeletal cephalometric parameters.

DISCUSSION
Sudheer Hongal et al. (2010) studied the malocclusion status and treatment needs in patients with cleft and plate. This was then compared and evaluated with non-cleft patients. This study consisted of 56 cleft lip and palate patients between 12-18 years of age and 168 non-cleft patients from the general population. The data was analysed with help of Dental Aesthics index (DAI). Around 51-78% of cleft patients and 35.71% of non-cleft patients scored a DAI of 26-30 suggestive of definite malocclusion. This study thus concluded that most patients with cleft lip and palate exhibited severe malocclusion and thus will led TMDs.

CONCLUSION
To present the occurrence of TMDs in cleft due to the inter jaw malocclusion, early treatment approach of TMJ deprogramming along with dental and surgical correction in CLP can present the occurrence of TMDs in CLP.

CONSENT
Consent will be taken for the participation in the study.