Maxillary dental anomalies in children with cleft lip and palate

CONTENTS
Introduction Embryology & Anatomy Etiology & Classification Occurance Risk Syndromes associated What can we expect Objective Material & Methods Statistical analysis RESULTS Discussion What this paper adds? Literature Review Conclusion

Embryology & Anatomy

1 Palate (4-7 weeks)

2 Palate (7-12 weeks)

Etiology

1. Genetic factors 2. Environmental factors 3. Gene-environment interactions

Classification
By Fogh Andersen (1942)

Group 1: Cleft of Lip - unilateral - bilateral - median

Group 2: Cleft of Lip and Palate - unilateral - bilateral

Group 3: Clefts of the Palate extending upto incisive foramen

Occurrence
0.5 to 3.63 per 1000 live births
Geographic section / race Incidence /1000

Negroes Caucasians Japanese Indians

0.5 1.0 2.34 1.27

 Incidence of different types of cleft

Type of cleft Cleft lip alone Cleft palate alone Both cleft lip and palate Incidence(% of all cleft cases) 25% 25% 50%

Combination of Cleft Lip and Palate

Isolated cleft palate

 Unilateral - common than bilateral defects unilateral - left-sided

Prevalence of different types of cleft in INDIA
PLACE
Dharwad Chennai Delhi

Types of Clefts with Percentage CLP CP CL 44.3 12.8 42.9 84.7 1.9 13.3 68 18 14

Risk
parental age - risk of affected child. consanguineous marriage - incidence of clefts . Genetics

Common syndromes associated with cleft lip and palate

Chromosomal Trisomy 13 Trisomy 18 Velocardiofacial syndrome (22q11 deletion) Mendelian disorders Ectrodactyly-ectodermal dysplasia-clefting syndrome (AD) Gorlin syndrome (AD) Oto-palato-digital syndrome (XL) Oral-facial-digital syndrome (XL) Smith-Lemli-Opitz syndrome (AR) Stickler syndrome (AD) Treacher Collins syndrome (AD) Van der Woude syndrome (AD)

Unknown de Lange syndrome Kabuki syndrome

Teratogenic Fetal alcohol syndrome Fetal phenytoin syndrome Fetal valproate syndrome

Non-Mendelian Pierre Robin sequence CHARGE association Goldenhar syndrome

What can we expect ?

dental anomalies
number size shape timing of formation eruption enamel dysplasia

 COMMON Missing, Supernumerary, Delayed development

Cleft area <=> outside cleft area

Objective
To evaluate the prevalence of dental abnormalities of the 1 & 2 maxillary dentitions in children affected by unilateral (UCLP) and bilateral (BCLP) cleft of the lip and palate.

Material & Methods

Affected
156 caucasian subjects
UCLP or BLCP non-syndromic

Control
1000 subjects - NCLP control sample
482 and 518 , and it was selected randomly None of the control subjects had received any orthodontic treatment.

92 and 64 mean age - 10 yrs 4 mnths

All had received the same surgical treatment
(early secondary gingivo-alveoloplasty, ESGAP) at

the mean age of 30 months

 Department of Orthodontics and Pediatric Dentistry of the University of Florence Subjects with inadequate dental records, craniofacial syndromes, or other medical disorders, were not included in the NCLP sample.

Clinical examination

Diagnostic cast

Intra oral pictures

radiographs

The following dental anomalies in the maxillary arch were recorded: aplasia of primary and permanent lateral incisors; aplasia of premolars; anomaly in shape: peg or conoid shape associated with reduced size; supernumerary teeth; and enamel hypoplasia of permanent incisors In UCLP subjects, - cleft side and non-cleft side, separately.

Male Female not considered separately.

Statistical analysis
The prevalence rates for the various dental anomalies were calculated in UCLP, BCLP, and total CLP groups, and they were contrasted to those in the NCLP group.

RESULTS
The statistical analysis revealed significant differences for the prevalence rates of all dental anomalies compared with the control group with the exception of the aplasia of the second premolars.

Discussion
CONGENITALLY MISSING TEETH:
LATERAL INCISORS permanent maxillary lateral incisor - most frequently missing in the cleft area. UCLP subjects- 8.1% for the primary lateral incisors and 27.9% for the permanent lateral incisors. (Primary Laterals overestimated ??)

Other authors : 45.3 58.6 %

 In BCLP, the prevalence rates for congenitally missing maxillary lateral incisors were much higher than in UCLP: 17% for the primary incisors, and 60% for the permanent incisors.
Other authors : 45 48.1% (permanent laterals)

SA: significantly greater prevalence in both UCLP and BCLP groups when compared with NCLP group.

CONGENITALLY MISSING: Second premolar

The maxillary second premolar was absent in 5.4% of UCLP subjects.
Ribeiro et al and Rose - 11.8 to 20.2% Tortora et al - 4.9%

In BCLP sample - congenital absence of the maxillary second premolar was found in 8.8% of the cases.
SA: No statistical significance UCLP/BLCP vs NCLP

SUPERNUMERARY TEETH
second most common dental anomaly in the cleft area

supernumerary teeth in the region of the maxillary incisors

permanent dentition 21.8% primary dentition 17.9%
Underestimated ?

supernumerary permanent teeth in the cleft area in UCLP children-25.2%

Ranta (20.9%) SA: significantly greater prevalence in both UCLP and BCLP groups when compared with NCLP group.

ANOMALIES IN SHAPE AND SIZE AND ENAMEL HYPOPLASIA OF PERMANENT TEETH

agenesis of teeth is related to an overall reduction in tooth size hypodontia and microdontia tend to occur in the same children In 48 subjects (35 UCLP & 13 BLCP), the permanent lateral incisor presented with some degree of anomaly in size or shape. The permanent central incisor is more frequently affected (23 UCLP & 14 BLCP ) than the permanent lateral incisors (2 UCLP & 2 BLCP).
SA: significantly greater prevalence in both UCLP and BCLP groups when compared with NCLP group

What this paper adds?

Provides information about maxillary dental anomalies both in children with UCLP and BCLP, and both in the primary and permanent dentitions. This investigation supports the theory that the effect of the cleft disturbance is more local than general on the dentition.

Literature Review
Incidence of Cleft Lip and Palate in British Columbia Indians (r. b. Lowry and d. h. g. Renwick) J. med. Genet. (1969).
CANADA

RATES PER 1000 LIVE BIRTHS IN BRITISH COLUMBIA IN 1952-1964 (RACE SPECIFIC) Type of Cleft Lip and or Palate Cleft lip only Cleft palate only Cleft lip and palate All forms of cleft lip and/ or palate Indian 0.25 0.44 2.48 3.17 Non-Indian 0.38 0.54 0.71 1.63

78% of the Indians with Cleft had the cleft lip and palate combination compared with 43 % in the non-Indian population. These studies show that the British Columbia Indian has a high frequency of oral clefts than that of the other American Indian groups.

 Primary dentition status and treatment needs of children with cleft lip and/ or palate (Ankola A. v.. Nagesh L.. Hegde P.,
Karibasappa G. N) - J. Ind. Soc. Pedod prev dent june 2005

The result of this study shows that: (1) all age groups of cleft affected children had dental caries experience (2) children with primary type of cleft had less dental caries prevalence than children with cleft of secondary or combination type

 Dental Abnormalities in the Deciduous and Permanent Dentitions of Individuals with Cleft Lip and Palate (bertram s. kraus, ronald e. jordan, and samuel pruzansky) - j dent res
Casts of 39 subjects with CL(P) were studied

1.The incisal edge is unusually thick labiolingually.

2. Excess mammelons 4 or more

3. Exaggerated mammelons - Unusually prominent, cusp like

4. Peg-shaped anterior teeth 5. T-shaped lateral incisors - A prominent ridge connecting the lingual tubercle with the incisal edge. 6. Abnormally shaped crowns with gross displacement of cusps.

7. Abnormally shaped maxillary first primary molars. 8. Complete absence of the distolingual cusp on maxillary second primary or first permanent molars. 9. Unusual reduction in size of the distolingual cusps of the maxillary second primary or first permanent molars. 10. Replacement of the distobuccal and mesiolingual cusps of the maxillary second primary or first permanent molars with a single cusp situated in the center of the oblique ridge.

11. Malformed mandibular bicuspids.

12.A deep fissure on the incisal edge of central or lateral incisors dividing the incisal edge into two moieties.

Morphological irregularities not only in cleft area, but in entire dentition

There was no indication that an affected deciduous tooth was succeeded by an affected permanent tooth.

Management of children with cleft lip and Palate: a review (peter d hodgkinson, susan brown, dorothy duncan, christine grant, amy mcnaughton, polly thomas and c rye mattick) Fetal and Maternal Medicine Review 2005 Non-syndromic CLP - 1 in 700 live births.

True prevalence is not known fetus aborted

CLP 3 times higher rate of stillbirths

 Caries, Gingivitis, and Dental Abnormalities in Preschool Children with Cleft Lip and/or Palate (goran dahllof, d.d.s., ph.d. reet ussisoo-joandi, d.d.s. margareta ideberg, d.d.s. thomas modeer, d.d.s., ph.d.) - cleft palate journal july 1989
CLP vs Normal Caries

number of gingival units with gingivitis.

 Timing and sequence of primary tooth eruption in children with cleft lip and palate (mrcia ribeiro gomide, cleide felcio de carvalho carrara)- J App Oral Science 2010

CLP vs Normal
Higher mean age of eruption of all primary teeth - max. & mand

The greatest delay was found for the maxillary lateral incisor

Conclusion

References
Timing and sequence of primary tooth eruption in children with cleft lip and palate (mrcia ribeiro gomide, cleide felcio de carvalho carrara)- J App Oral Science 2010 Caries, Gingivitis, and Dental Abnormalities in Preschool Children with Cleft Lip and/or Palate (goran dahllof, d.d.s., ph.d. reet ussisoo-joandi, d.d.s. margareta ideberg, d.d.s. thomas modeer, d.d.s., ph.d.) - cleft palate journal july 1989 Management of children with cleft lip and Palate: a review (peter d hodgkinson, susan brown, dorothy duncan, christine grant, amy mcnaughton, polly thomas and c rye mattick) Fetal and Maternal Medicine Review 2005

 Dental Abnormalities in the Deciduous and Permanent Dentitions of Individuals with Cleft Lip and Palate (bertram s. kraus, ronald e. jordan, and samuel pruzansky) - j dent res
Incidence of Cleft Lip and Palate in British Columbia Indians (r. b. Lowry and d. h. g. Renwick) J. med. Genet. (1969).

Primary dentition status and treatment needs of children with cleft lip and/ or palate (Ankola A. v.. Nagesh L.. Hegde P.,
Karibasappa G. N) - J. Ind. Soc. Pedod prev dent june 2005 Dentistry for the child and adolescent McDonald, Avery Human embryology nderbir Singh 7th ed Text book of pediatric dentistry Nikhil Marwah Text book of pedodontics Shoba Tandon 2nd ed