Open Journal of Stomatology, 2013, 3, 31-36 OJST
http://dx.doi.org/10.4236/ojst.2013.39A005 Published Online December 2013 (http://www.scirp.org/journal/ojst/)
Assessment of alveolar defect volume in unilateral cleft lip
and palate patients using a free software program
Patricia Picolli1, Luciane Macedo de Menezes2*, Márcia Brucker 3, Fabiane Azeredo2,
Susana Maria Deon Rizzatto2
1Private Practice, Porto Alegre, Brazil
2Department of Orthodontics, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
3Department of Radiology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
Received 11 September 2013; revised 19 October 2013; accepted 13 November 2013
Copyright © 2013 Patricia Picolli et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The purpose of this study was to assess the alveolar
defect volume in unilateral cleft lip and palate (UCLP)
subjects using computed tomography (CT) and a free
software program to evaluate the intra- and inter-
rater measurements, and to compare the cleft volume
between age and affected side. The sample of this
retrospective study consisted of 20 UCLP individuals,
12 boys and 8 girls, mean age 10.3 ± 2.4 years at the
beginning of orthodontic treatment. All subjects re-
quired alveolar bone grafting. CT scans of the cleft
area were obtained prior to secondary bone grafting,
and were analyzed using Image J. software program.
The cleft volume was calculated based on axial cross-
sectional CT images by two raters (orthodontist and
radiologist) and by the same rater (orthodontist) at
two different moments. Linear mixed model, Bland-
Altman, Pearson’s and intraclass correlation coeffi-
cient (ICC) were used. The mean cleft volume was
7.53 ± 1.55 mm³. The intra- and inter-rater measure-
ments were reproducible (ICC = 0.976 and 0.963, re-
spectively) with no significant difference between
them. There were no statistically significant differ-
ences in the cleft volume related to age or cleft loca-
tion. The assessment of cleft volume in UCLP using
CT images and a free software program was a re-
producible method. There was no significant relation
between alveolar defect volume and age or cleft loca-
Keywords: Alveolar Process; Cleft Palate; Computed
Tomography; Volumetric Assessment
Secondary bone grafting is considered the gold standard
for repairing the cleft region . It is indicated for most
patients with an alveolar cleft, the best stage for this
procedure is in the mixed dentition when the canine ad-
jacent to the cleft has completed half to three quarters of
its root formation . Its major benefit is to restore al-
veolar integrity to induce spontaneous migration of per-
manent teeth adjacent to the cleft in the newly formed
bone [3,4]. The outcome of the surgery is considered
satisfactory when sufficient volume of normally remod-
eled bone tissue is obtained . Secondary bone grafting
enhances the dental alveolus for eruption and periodontal
support of the teeth adjacent to the cleft, usually the ca-
nine and the lateral incisor [2,6,7]. This allows, through
orthodontic treatment, the closing of the residual space,
and in many cases it does not require rehabilitation with
prosthesis or implants. Furthermore, the alveolar bone
graft bridges the cleft defect with bone, providing an alar
base support and allowing closure of the communication
between the oral and n asal cavities [5,8,9].
Fresh autogenous bone is the ideal bone graft material
because it supplies living immunocompatible bone cells
essential to osteogenesis [10,11]. For optimum osteo-
conductive, osteoinductive and osteogenic properties,
autogenous cancellous bone from the ilium is preferred
 due to the easy access and the large amount of bone
tissue that can be obtained from this area [11,13]. How-
ever, even though the iliac crest can produce an abundant
amount of bone tissue for grafting , it is important to
obtain an accurate estimation of the alveolar cleft volume
and its architecture to determine the quantity of bone to
be collected prior to the surgery and thus, to avoid in-
adequate bone harvesting (reduced or excessive) as well
as to reduce the postoperative morbidity of the donor
*Corresponding a uthor.
P. Picolli et al. / Open Journal of Stomatology 3 (2013) 31-36
region . Another material, such as allogeneic bone,
can present an advantage in terms of reduced morbidity,
and can be used during alveolar bone grafting, but it is
not as beneficial as autogenous bone [11,15]. Favorable
results using bone morphogenetic protein 2 (BMP-2) for
reconstruction of the alveolar cleft have been reported in
the literature, but more studies are necessary to assess the
bone quality in the long term .
Loss of the bone graft, reopening of the oronasal fis-
tula, or both can happen, although secondary bone graft
failures are considered uncommon . Besides the il-
ium, the literature has reported high rates of success with
other donor sources as tibia, mandibular symphysis and
calvarial bone [17,18].
Progress related to Computed Tomography (CT) has
contributed to the virtual representation of craniofacial
anatomy and provides visualization of bone defects and
measurements of dentoalveolar areas . Although
conventional X-rays allow 2-dimensional (2D) assess-
ment, the inability to assess the volume, buccolingual
morphology and architecture of the cleft are the main
disadvantages inherent to this method . The use of
CT images enables the creatio n of three-dimensional (3D)
virtual models of anatomical structures. These images
allow better accuracy as well as segmentation of struc-
tures for 3D analysis [20,21]. Therefore, the estimation
of the bone amount required for grafting in the alveolar
cleft area can be predicted by using surgical simulation
software programs based on 3D CT images . The CT
images are stored by using Digital Imaging and Commu-
nications in Medicine (DICOM) format, and there is a
wide range of software packages and applications avail-
able, even freeware, dedicated to managing and analyz-
ing the DICOM images, working on them, and exporting
sections of images in other formats [22-24], therefore
those images can be used for various measurements
The purpose of this study was to determine the bone
defect volume in a group of patients with unilateral com-
plete cleft lip and palate (UCLP), prior to secondary
bone grafting, using CT images and a free software pro-
gram, to analyze the reproducibility of intra- and inter-
raters measurements and to compare the cleft volume
between age and the affected side.
2. MATERIALS AND METHODS
2.1. Sample Characteristics
The sample of this retrospective study using multi-slice
spiral CT scans consisted of twenty patients with UCLP
seeking care in the Cleft Lip and Palate Rehabilitation
Center (CERLAP) at Pontifical Catholic University of
Rio Grande do Sul (PUCRS). The patients included 12
boys and 8 girls, with no previous orthodontic and or-
thopedic treatment. The mean age at the beginning of the
treatment was 10.3 years (SD = 2.49 years). The cleft
location was on the right side in 12 patients and 8
showed left-sided clefts (Table 1). Patients with con-
genital malformation s, syndromes, periodontal disease or
those aged 15 years or older were excluded from the
study. An informed consent for research, approved by
the PUCRS Scientific Research Ethics Committee, was
obtained ( 08/04364).
2.2. CT Data Acquisition and Measurements
Selected acquisition parameters in the command console
of the spiral CT Elscint (Elscint Ltd., Haifa, Israel) were
the following: gantry zero degree with laser-guide coin-
ciding with the Frankfurt plane of the patients, 120 kVp
tube voltage and 150 mA tube current, 14 cm field-of-
view (FOV), 512 × 512 of matrix. CT image protocol
consisted of axial cross-sectional slices of the region of
interest (from the nasal cavity to the occlusal plane) with
0.5 mm slice thickness. The DICOM CT images were
assessed and the alveolar cleft volumes were measured
using the Image J. software program (version 1.38, avai-
lable at http://rsbweb.nih.gov/ij/).
The alveolar bone defect was free-handedly traced on
each of the axial cross-sectional images. The first slice
that allowed the visualization of the alveo lar margin sur-
rounding the cleft was considered the lower limit; this
was followed by the delimitation of the alveolar cleft in
all slices, until the image of the floor of the nostril (con-
sidered the upper limit). The measurement of the
bounded area on each slice provided a sequence of indi-
vidualized measures. The sum of these measures resulted
in the total area of the bone defect. The region of interest
was then analyzed in accordance to the method proposed
by Feichtinger et al. . All procedures of delineation
and measurement of the cleft area were performed twice
by the same examiner (an orthodontist, P.P.), and a
minimum interval of thirty days elapsed between meas-
urements to assess the differences between intra-rater
(orthodontist 1st and 2nd measurements). A second ex-
aminer (a radiologist, M.B.) performed the measure-
Table 1. Patient characteristics.
Characteristics n = 20
Age (years), mean ± SD
(minimum to maximum) 10.30 ± 2.49
(7 to 14)
Gender, no. (%)
Cleft location, no. (%)
Cleft volume (mm3), mean ± SD
(minimum to maximum) 7.53 ± 1.55
(4.77 to 10.20)
Copyright © 2013 SciRes. OPEN ACCESS
P. Picolli et al. / Open Journal of Stomatology 3 (2013) 31-36 33
ments once and differences between inter-rater (ortho-
dontist and radiologist) were evaluated. The examiners
were blinded to perform the measurements.
2.3. Statistical Analysis
Continuous data were described using mean, standard
deviation, minimum and maximum values. Categorical
data were presented as counts and percentages. To
evaluate observer agreement (within and between com-
ponents) it was initially calculated th e Pearson’s correla-
tion coefficient. This approach was followed by the in-
traclass correlation coefficient (ICC) and Bland-Alt-
man’s plot with difference bias and 95% limits of
agreement. The influence of selected factors (age and
affected side) on cleft volume was explored using a lin-
ear mixed model considering all three measurements
available for each patient. Significance level was set at α
= 0.05. Data were analyzed using SPSS version 18.0.
The intra- and inter-rater measurements were reproduce-
ble (ICC = 0.976 and 0.963, respectively) and compare-
sons showed a strong association with no significant dif-
ference among measurements (Figure 1).
The mean volume corresponding to the initial alveolar
defect of the cleft in this study was 7.53 ± 1.55 mm³,
ranging from 4.77 to 10.20 mm³ (Table 1).
Although no statistically significan t, the age presented
a borderline significance (p = 0.097), and it could be an
influent factor in the alveolar cleft volume. There was no
statistically significant impact of the cleft side (right or
left) on the cleft volume (p = 0.687).
Secondary bone grafting is an essential step in alveolar
deformity reconstruction in cleft lip and palate (CLP)
patients . In addition to the benefits recognized in
creating bone suppo rt for tooth eruption [15,2 7], second-
dary bone grafting allows the elimination of oronasal
fistulae, improves oral hygiene by separating the dental
and nasal cavities, rebuilds the hypoplastic pyriform ap-
erture  and the soft tissue of the nasal base support
, and stabilizes the maxillary arch , thus provid-
ing a suitable volume of bone to allow dental movement
and subsequent residual space closure in the cleft region
. The recognition of the initial size of the alveolar
defect and the use of reproducible measurement methods
are essential factors in studies that evaluate the stability
of alveolar grafting .
The measurements in this study presented excellent
examiner repeatability (Figure 1), and the mean volume
corresponding to the preoperative alveolar defect was
7.53 ± 1.55 mm³ (Table 1). Other studies reported higher
mean volumes of the alveolar defects (11.0 to 38.0 mm³)
[10,26,30-32]. However, previous orthopedic procedures
were not mentioned in those researches. In the present
study, the sample consisted of patients with no previous
orthodontic and orthopedic procedures when the CT
scans were taken. Therefore, the difference among cleft
volume values could be explained by the maxillary ex-
pansion and orthopedic protraction performed to correct
the sagittal and transverse deficiency [33,34], usually
performed before the secondary bone graft .
In a study based on radiographs, Aurouze et al. 
reported that there was no correlation between the alveo-
lar cleft size and the success in secondary alveolar graft-
ing. However, van der Meij et al.  evaluating this
topic on CT scans, indicated that there could be a posi-
tive correlation (i.e., bigger clefts would be more prone
to have alveolar graft resorption due to insufficient vas-
cularization of progenitor cells in the center of the bone
graft) . According to Shirota et al.  it is impor-
tant to understand the architecture of the alveolar defect
in the cleft area and to assess its volume using CT im-
ages prior to the surgical procedure to obtain the correct
volume necessary for bone grafting. Although CT is still
used in situations when 3D information is required, do-
simetry studies demonstrated that the absorbed and ef-
fective doses of spiral and conventional CT were higher
than that using cone beam CT (CBCT) [39-41]. Fur-
thermore, the CBCT technology has other advantages
over CT such as lower cost, shorter acquisition time,
better resolution, greater detail, being more appropriate
for dentistry [42-47]. However, spiral CT was used in
this retrospective study because the access to CBCT
scanners in the early 2000’s (when the cleft patients’ data
were acquired) was difficult.
For alveolar defect repair, autogenous bone can be
harvested from intraoral sites (limited to the amount of
bone available), such as the mandibular symphysis,
retromolar pad, mandibular ramus, tuberosity and zygo-
matic buttress, and from extraoral sites, such as the tibia,
and iliac crest . Although the iliac crest can provide
an abundant bone amount for grafting , the preopera-
tive computer simulation and assessment of the 3D al-
veolar cleft volume using CT images can avoid the in-
adequate harvest of bone as well as reducing the postop-
erative morbidity of the donor region . This can pre-
vent some of the possible surgical complications such as
excessive blood loss, delayed wound healing, pain and
hypoesthesia . The mandibular symphysis, an in-
traoral donor site with a reduced morbidity, is not a do-
nor area that provides sufficient volume of cancellous
bone  to fill in all kinds of alveolar cleft defects.
Thus, it is essential to assess the cleft dimensions to se-
lect the adequate donor site and harvest the needed
amount of bone for the alveolar graft .
Copyright © 2013 SciRes. OPEN ACCESS
P. Picolli et al. / Open Journal of Stomatology 3 (2013) 31-36
Copyright © 2013 SciRes.
Figure 1. Linear scatter and Bland-Altman plots for the comparison among observers.
Due to the popularizatio n of 3D imaging as a means to
assist in dental diagnosis, this study assessed its clinical
applicability using a public domain software program. It
was possible to delimitate the alveolar bone defect in the
cleft region, as well as to obtain its respective measure-
ments in CT slices [51-53]. Considering the lack of spe-
cific researches in the literature regarding the applicabil-
ity of free software programs for the evaluation of bone
deformity in cleft patients, this study showed a repro-
ducible method to assess and measure the alveolar cleft
In this study, the assessment as well as measurements in
cleft patients using CT images and a free software pro-
gram was a reproducible method.
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