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ORIGINAL ARTICLE
Year : 2011  |  Volume : 29  |  Issue : 3  |  Page : 229-234
 

Post-surgical dentofacial deformities and dental treatment needs in cleft-lip-palate children: A clinical study


1 Department of Pedodontics and Preventive Dentistry, Army Dental College, Secunderabad, India
2 Department of Pedodontics and Preventive Dentistry, Govt. Dental College, Hyderabad, India
3 Department of Pedodontics and Preventive Dentistry, K. D. Dental College, Mathura, India

Date of Web Publication10-Oct-2011

Correspondence Address:
V Krishna Priya
Department of Pedodontics & Preventive Dentistry, MNR Dental College & Hospital, Sangareddy, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.85831

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   Abstract 

Background: Cleft lip and palate is a common congenital defect. It is one of the most common facial deformities occurring in major racial and ethnic groups. Aims: The aim of the present study was to record the post-surgical dentofacial deformities in operated cleft lip and palate children, as well as to assess the multitude and magnitude of their dental and other related problems so as to formulate an appropriate treatment plan for complete oral rehabilitation of these children. Materials and Methods: The present in vivo study was conducted on 50 operated cleft lip and palate children (23 males and 27 females) ranging from 3 to 14 years of age in an attempt to evaluate the post-surgical dentofacial abnormalities in these children. Results and Conclusions: The study revealed that the distribution of cleft deformity is shown out of 23 male children, 11 children with unilateral cleft lip, 9 children with bilateral cleft lip palate, and remaining 3 children were with cleft palate. Out of 27 female children, 19 children with unilateral cleft lip palate, 3 children with bilateral cleft lip palate, and 5 children with cleft palate. This study showed a wide range of surgical, dental, and functional problems in all operated cleft lip and palate patients. Hence, the study concluded that the effect of timing of the cleft repair on the overall development of facio skeletal-dental structures showed insignificant differences among the various operated cleft-lip-palate children.


Keywords: Cleft lip and palate, consanguinity, malocclusion, maternal age, premaxilla, sexual dimorphism


How to cite this article:
Priya V K, Reddy J S, Ramakrishna Y, Reddy C P. Post-surgical dentofacial deformities and dental treatment needs in cleft-lip-palate children: A clinical study. J Indian Soc Pedod Prev Dent 2011;29:229-34

How to cite this URL:
Priya V K, Reddy J S, Ramakrishna Y, Reddy C P. Post-surgical dentofacial deformities and dental treatment needs in cleft-lip-palate children: A clinical study. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2019 Jul 15];29:229-34. Available from: http://www.jisppd.com/text.asp?2011/29/3/229/85831



   Introduction Top


Cleft lip and palate is one of the most common facial deformities occurring in all major racial and ethnic groups.. Clefts occur in families from every social, educational and economical level and are particularly distressing, because most of these children are otherwise normal. Children with cleft lip and palate face multiple complex problems including deficits in growth and development.

Even after undergoing surgical procedures, many facial and oral deformities are found in cleft lip and palate children who require dentist's intervention. Some of the deformities include reduced growth of maxilla, [1] deficiency of hard palate tissue even after operating cleft palate cases, lateral displacement of oro-nasal area as compared to others, [2],[3] maxilla and palatine bones are retroplaced as compared to the non-cleft side. [4]

Hence, this present study was conducted to evaluate the post-surgical dentofacial abnormalities in operated cleft lip and palate children.


   Materials and Methods Top


A sample of 50 patients in the age group of 3−14 years who had underwent cleft lip and palate surgery in the Department of Plastic Surgery, Osmania General Hospital, Hyderabad were included in the study. They had reported to Department of Pedodontics, Govt Dental College and Hospital, Hyderabad, for various dental treatment needs. A case sheet was prepared which included the general data and all the parameters need for the study. The parameters which were considered are:

  • Type of cleft lip-palate
  • Age at which surgery was done
  • Sexual dimorphism
  • Consanguinity
  • Facial abnormalities
  • Malocclusion
  • Speech
  • Dental anomalies


Type of cleft lip palate

The changes in clinical classification of oral clefts reflect both increased knowledge of embryology and the historical development of the treatment of clefts. The first generally accepted classification was developed by Davis and Ritchie in 1922.This is a three group classification of clefts, with the alveolus as the demarcation point between cleft lip and cleft palate as opposed to today's incisive foramen.

  • Cleft lip (unilateral, median or bilateral)
  • Cleft palate (soft palate, hard palate)
  • Cleft lip and palate (unilateral, median and bilateral).


All the cases are evaluated whether they are unilateral or bilateral clefts. All the unilateral clefts in the study were considered for right or left side occurrence. [Figure 1] and [Figure 2]a
Figure 1: Operated unilateral cleft lip-palate with deviated nose towards non-cleft side

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Figure 2: (a)Operated unilateral cleft lip-palate
Figure 2b: Operated unilateral cleft lip-palate showing class III profile


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Age at which surgery was done

Cleft lip repair must be performed when the child is in good health. Most surgeons follow " rule of ten" according to which surgery should be performed when the infant is at least 10 weeks old, weighs 10 pounds, has a hemoglobin count of 10 gms/dl and has a white blood cell count no higher than 10,000/mm 2 . Early cleft lip repair is aimed to create the functional balance of the facial musculature, facilitate feeding, and minimize the traumatic experience of the patients and parents physically as well as socially to influence symmetric growth of the mid-face.

The age at which the surgery was done was recorded.

Sexual dimorphism

Males are affected more than the females as seen from cleft lip palate literature the world over. The sex ratio in patients with clefts varies. In whites, cleft lip and palate occur significantly more common in males and cleft palate occurs in females.

Consanguinity

Consanguinous marriages have a greater number of congenital defects including cleft lip and palate. All the parents were enquired regarding the family history and consanguinal marriages.

Facial abnormalities and malocclusion

The principal surgical goal is the same: to establish good function, which inturn will permit optimum subsequent growth and development of the facial skeleton. This principle is important both in primary and secondary cleft corrections because good function is a pre-requisite to good facial esthetics. The characterization of dento-facial anomalies included facial pattern and malocclusion for those between 6 and 13 years of age. (Primary and permanent teeth). Angle's classification was used in malocclusion assessment (Angle, 1899). In addition, anterior open bite, anterior and posterior crossbite and crowding in upper and lower incisal segments were registered [Figure 2]b.

Dental anomalies

Dental anomalies occur frequently in cleft lip and palate patients. Frequently encountered dental abnormalities in cleft lip and palate children are variations in tooth size, location, congenital absence of teeth particularly the maxillary lateral incisors at the site of the cleft.[Figure 3] and [Figure 4]
Figure 3: Premaxilla protrusion with hypoplastic tooth

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Figure 4: Operated cleft region showing irregular, missing, and hypoplastic teeth

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Speech

Palatoplasty technique the possible need for secondary surgical management therapy vs. no therapy, appropriate stimulation by family, and cognitive function, children with cleft palate do begin to show improvements in speech sound development as a result of surgical intervention. However, acquisition of age appropriate speech is not achieved immediately and quickly for many of these children; in order to develop better idea of what speech outcomes can and should be expected after palatal surgery it is also important to investigate speech development of these children before surgery has taken place.

A detailed case history with all the parameters were recorded. The results are tabulated and subjected to statistical analysis.


   Results Top


  • In this study, distribution of cleft deformity has been depicted in [Table 1]
  • Table 1: Distribution of cleft deformity in cleft lip-palate cases

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  • Etiology of cleft-lip and palate cases has been depicted in [Table 2]
  • Table 2: Etiology of cleft lip-palate cases

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  • Distribution of cleft-lip and palate cases in different age groups has been depicted in [Table 3]
  • Table 3: Distribution of cleft lip-palate cases in different age groups

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  • Age group under which the surgical procedure undertaken for primary lip surgery depicted in [Table 4]
  • Table 4: Surgical procedure undertaken – primary lip surgery

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  • Age group under which the surgical procedure undertaken for palatal push back depicted in [Table 5]
  • Table 5: Surgical procedures undertaken – palatal push back

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  • Post-surgical deformities of lip were depicted in [Table 6]
  • Table 6: Post-surgical deformities of lip

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  • Post-surgical deformities of pre-maxilla were depicted in [Table 7]
  • Table 7: Post-surgical deformities of pre-maxilla in unilateral and bilateral cleft lip-palate children

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  • Cases with residual palatal defects and cleft speech has been shown in [Table 8]
  • Table 8: Cases with residual palatal defects

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  • Incidence of malocclusion in operated cleft lip and cleft palate patients has been shown in [Table 9]
  • Table 9: Malocclusion in operated cleft lip-palate cases

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  • Various tooth abnormalities in operated cleft lip and palate children has been shown in [Table 10]
  • Table 10: Tooth abnormalities in operated cleft lip-palate cases

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  • Age at which the lip surgery is performed and dentofacial abnormalities has been shown in [Table 11]
  • Table 11: Timing of lip surgery and post-surgical deformities

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  • Age at which palatal surgery is performed and the dento facial abnormalities has been shown in [Table 12]
  • Table 12: Timing of palatal surgery and post-surgical deformities

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  • Treatment needs of cleft lip and palate children has been depicted in [Table 13]
Table 13: Dental treatment needs of cleft-lip and palate children

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   Discussion Top


The study is basically on post-surgical dento facial deformities in cleft lip palate patients. No surgical regime is being followed and many patients were operated in one hospital for lip surgery and in another hospital for palate repair. In majority of the patients both lip surgery and palatal surgeries were delayed. Early esthetic and functional rehabilitation of children with cleft lip and palate has been considered a major goal. Surgical advancement of the mid-face has become a relatively common procedure in these patients.

The results obtained with regard to distribution of cleft deformity i.e. unilateral cleft lip and palate (60%) bilateral cleft lip and palate (24%) and isolated cleft palate (16%) were almost in agreement with values given by Perez Molina. [5] The increased incidence of cleft lip and palate when compared to isolated cleft palate was in accordance with the results given by Derijeke et al, [6] but showed marked contrast to that of Greg et al, [7] who gave 53% occurrence to isolated cleft palate and 31% to cleft lip and palate. About 56% of the samples parents gave positive history for consanguineous marriage. About one-third of cases with cleft lip and palate has a positive family history and the incidence and significance of this finding is discussed by Bhatia et al.[8]

With respect to the pattern of distribution of cases with regarding the timing of lip and palatal repair 42% of the cases had underwent the surgical procedure for both lip and palatal repair in between 3−5 years age group, 32% of the cases were in between 6−8 years age group, 10% of the cases were in between 12-14 years age group. According to the timings of surgery, 4% of the total sample underwent palatal repair in the age group of 0−1 years, 16% in the age group of 2−3 years, 20% in the age group of 4−6 years, 14% in the age group of 7−9 years, 6% in the age group of 9−12 years, and 8% in the age group of 12−14 years. About 42% of the total sample underwent primary lip repair in the age group of 0−1 years and 16% in the age group of 1−2 years, 2% in the age group of 2−3 years, 12% in the age group of 7−9 years. Filho suggested that it is lip repair more than palatal surgery that may adversely affect dento facial morphology. In this study, 30% showed lip notching, 10% showed short upper lip, 10% showed absence of cupids bow, and 60% of the cases showed deficient vermilion border. Saunders D E et al, showed high percentage of lips that were too short. [9]

In this study, 38% of the cases who had undergone palatoplasty in between the age group of 1−2 years showed residual palatal defects and 63% of the cases in 2−3 years age group, 60% of the cases in 4−6 years, 56% in 7−9 years, 66% in 9−12 years, and 75% in 12−14 years age group palatoplasty was usually scheduled at around 18 months in cleft palate patients. In this study, 92% of the cases showed cleft speech who had undergone palatoplasty in1−14 years.

In this study, 12.5% of the cases showed anterior crossbite in the children who had undergone palatal repair in the age group of 1−2 years and 20% of the cases showed anterior crossbite in 4−6 years group. Hellquist et al,[10] stated that the frequency of cross bite in cleft lip and or palate children is influenced by the type and size of the cleft, as well as the timing of the method of the surgical intervention [Table 11] and [Table 12].

Treatment of a patient with cleft lip and palate requires a multidisciplinary approach. The data of various evaluation procedures independently and all together represent the standards of cleft care and spectrum of problems in cleft children visiting the hospital. From this spectrum of problems a need based treatment strategy can be grafted, which is best for the patient and parents. The findings of this study suggest poor dental arch relations in most of the patients and also suggest the need for the development of integrated team approach with well defined treatment protocol for the care of cleft lip and palate patients.


   Summary and Conclusion Top


It may be concluded from the observations of the present study that the effect of timing of the cleft repair on the overall development of facio skeletal-dental structures showed insignificant differences among the various operated cleft-lip-palate children. Various dento facial abnormalities resulted in individuals are results of many other factors like type of surgery done, aberrant growth patterns under the influence of functional imbalance of the associated structures. As the etiology of cleft-lip-palate is multi-factorial and resulted complications are multi-dimensional, more number of longitudinal studies involving large number of cases are required to assess the multitude and magnitude of the various dento facial abnormalities incidence and treatment needs of cleft lip palate individuals.

 
   References Top

1.Jolleys A. A review of the results of the operations on cleft palate with references to maxillary growth and speech function. Br J Plast Surg 1954;7:229-4.  Back to cited text no. 1
[PUBMED]    
2.Coupe TB. Cleft palate deficiency or displacement of tissue. Plast Reconstr Surg 1960;26:600-12.  Back to cited text no. 2
    
3.Subtenly JD. A Cephalometric study of the growth of the soft palate. Plast Reconstr Surg 1957;19:49-62.  Back to cited text no. 3
    
4.Atherton JD. Morphology of facial bones in skulls with unoperated unilateral cleft palate. Cleft Palate J 1967;4:18-30.  Back to cited text no. 4
[PUBMED]    
5.Perez M. The prevalence of risk factors of cleft lip and palate in Guadalajara. Mexican Med Hosp Bull 1993;50:110-3.   Back to cited text no. 5
    
6.Derijcke A, Eeren A, Carels C. The incidence of oral clefts - A review. Br J Oral Maxillofac Surg 1996;34:488-94.  Back to cited text no. 6
    
7.Greg T, Boyd D,Richardson A. The incidence of cleft lip and palate in Northern Ireland from 1980-1990. Br J Orthod 1994;21:387-92.  Back to cited text no. 7
    
8.Bhatia SN. Genetics of cleft lip and palate. Br Dent J 1972;132:95-103   Back to cited text no. 8
    
9.Saunders DE, Hochberg J, Gray HW, Grauzam R, Deleeu WN. An evaluation of unilateral cleft lip repairs. Presented at the American Society of Plastic & Reconstructive Surgeons annual meeting, Toronto, Ontario, Oct 21, 1975.  Back to cited text no. 9
    
10.Hellquist R, Skoog T. The influence of primary periosteoplasty on facial growth and deciduous occlusion in cases of complete unilateral cleft lip and palate. Scan J Plast Reconstr Surg 1976;10:197-208.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]


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