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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 59-64

Pattern of malocclusion and caries experience in unrepaired cleft lip and palate patients in Enugu


1 Department of Restorative Dentistry, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
2 Department of Plastic Surgery, National Orthopaedic Hospital Enugu, Enugu State, Nigeria
3 Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
4 Department of General Surgery, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria

Date of Submission03-May-2019
Date of Acceptance27-Sep-2019
Date of Web Publication10-Jan-2020

Correspondence Address:
Dr. L O Okoye
Department of Restorative Dentistry, College of Medicine, University of Nigeria Enugu Campus, Enugu State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_249_19

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   Abstract 


Background: Clefts are common birth defects, usually accompanied by various malformations that include malocclusions, and may be associated with tooth decay. The aim of this study was to assess the malocclusion and caries status of the patients with unrepaired clefts who presented at the National Orthopaedic Hospital Enugu. Subjects and Methods: A cross-sectional, descriptive study was conducted among patients with unrepaired cleft lip and/or palate that presented at the National Orthopaedic Hospital, Enugu between January 2009 and December 2011. Detailed records of 140 patients with cleft deformities who presented to the hospital within the study period were analyzed for the cleft pattern, whereas those patients above 6 years of age (52 patients) were analyzed for malocclusion using the Angle's classification of malocclusion. Assessment for dental caries according to WHO guidelines was made for all the patients. Result: There were 74 males and 66 females. Cleft lip with or without alveolus involvement had equal prevalence (47.1%) (66 patients) with combined cleft lip and palate; eight patients had isolated cleft palate (4.71%). Angle's class 1 malocclusion was statistically significantly higher than other classes (P = 0.000). Class I malocclusion was seen in 38 patients (73.1%), whereas class 111 was seen in 8 patients (15.4%) and class 11 in 6 patients (11.5%). Eight patients (100%) who developed class 111 malocclusion all had a hard palatal defect. Proclining of maxillary anterior teeth (increased overjet) was the most common orthodontic anomalies, reported in 25 patients (48.1%) (P = 0.002). Caries prevalence of 12.9% was observed in this study. Caries experience was statistically significantly higher in deciduous than permanent teeth (P = 0.002). Conclusion: The high prevalence of malocclusion in these cleft patients emphasizes the need for an interdisciplinary team approach and early inclusion of dental care especially oral hygiene to prevent tooth decays.

Keywords: Angle's classification, caries, cleft lip and palate, malocclusion


How to cite this article:
Okoye L O, Onah I I, Ekwueme O C, Agu K A. Pattern of malocclusion and caries experience in unrepaired cleft lip and palate patients in Enugu. Niger J Clin Pract 2020;23:59-64

How to cite this URL:
Okoye L O, Onah I I, Ekwueme O C, Agu K A. Pattern of malocclusion and caries experience in unrepaired cleft lip and palate patients in Enugu. Niger J Clin Pract [serial online] 2020 [cited 2020 Jan 25];23:59-64. Available from: http://www.njcponline.com/text.asp?2020/23/1/59/275618




   Introduction Top


C left lip and/or palate (CLP) is one of the most frequent congenital defects and is mainly accompanied by a variety of malformations, such as disturbances in facial appearance as well as skeletal disorders that include malocclusions.[1] Oral clefts mainly comprise lips, alveolar arches, and hard and soft palates. The World Health Organization[2] reported that CLP is a major dental health issue as it affects the individual psychologically, esthetically, and functionally. Jac-Okereke and Onah[3] in a recent study reported an incidence of 1:934 among Igbos.

Malocclusion is irregularity that leads to disfigurement hampering the function of teeth, which is likely to be an impediment to the patient's physical or emotional comfort.[4] Malocclusion compromises the health of the oral cavity and can lead to social problems in affected patients.[4] It is the second most common dental disease in patients after caries.[5] Malocclusions and cleft abnormalities have been described,[3],[6] however, there are few studies that have associated malocclusions with oral clefts.[1],[7]

Baek et al.[8] reported similarity between types of malocclusion and diverse classification of oral clefts among the Koreans. He also observed that the type of cleft significantly influenced the development of a class III malocclusion. Higher frequencies of crossbite and open bite have been reported among patients with clefts.[1],[9],[10] Chopra et al.,[10] reported that anterior open bite and increased overjet were more prevalent among children with clefts. Hypodontia has been reported in 70% of individuals with complete bilateral CLP: the maxillary lateral incisor was the most affected tooth. The same study[10] reported supernumerary teeth in 11.7% of the subjects. Tereza et al.[11] reported agenesis of at least one tooth in approximately 60% of patients aged 10.5–13.5 years with complete bilateral CLP. The teeth most frequently missing were the maxillary lateral incisors, the maxillary, and mandibular second premolars.

It has also been observed[12] that patients with cleft conditions are not only at a high risk of caries but also have a higher prevalence of caries than individuals without cleft, whereas some researchers[13],[14] found no significant differences in caries between children with and those without a cleft. Although work on cleft lip with or without palate involvement has been published severally[3],[15],[16] from Nigeria, we are unaware of publications from southeastern Nigeria on the pattern of malocclusion and caries experience among this group of patients. An improved understanding of the pattern of malocclusion and caries experience among this group of patients will facilitate appropriate treatment planning and evidenced-information for counseling of cleft patients and their parents. Therefore, the need for this present study to assess the malocclusion status and caries experience of the patients with unrepaired clefts presenting at the National Orthopaedic Hospital in Enugu metropolitan city located in the South Eastern region of Nigeria.


   Subjects and Methods Top


Study design

This cross-sectional and descriptive study was carried out on cleft patients attending plastic surgery clinics at National Orthopaedic Hospital, Enugu from January 2009 to December 2011.

Ethical considerations

Ethical clearance was obtained from the Research and Ethics committee of University of Nigeria Teaching Hospital Enugu. Informed consent was obtained from either the parents/guardians or patients.

Subject recruitment

All cleft patients who presented to the plastic surgery clinics of National Orthopaedic Hospital, Enugu from January 2009 to December 2011, without prior surgical intervention were recruited in this study.

Inclusion criteria

Patients who have not had any surgical intervention.

Patients who gave consent.

Patients whose indicator teeth (upper and lower permanent first molar) have erupted into occlusion.

Exclusion criteria

Patients who had surgery before attending the clinics.

Patients who declined consent.

Patients whose indicator teeth have not erupted into occlusion.

Data collection

A structured, interviewer administered-questionnaire responded to by patients or their parents or guardian were used to collect demographic information on the subjects including age, sex, type of the cleft, and oral hygiene habits.

Clinical examination and orthodontic analysis

To ensure accurate analysis and classification of malocclusion as well as dental caries assessment, the primary examiner was trained and calibrated by an expert examiner (a consultant orthodontist) on the classification of malocclusion and analysis of dental anomalies, while she calibrated herself on the assessment for dental caries in permanent and deciduous teeth.

The first six subjects that were recruited into the study were used for the calibration exercise. The agreement between the benchmark examiner and the primary examiner (inter-examiner agreement) and the primary examiner individual evaluation (intra-examiner reliability) were evaluated using the unweighted kappa (κ) statistic. The primary examiner was also calibrated for assessment of dental caries using the decayed, missing, and filled Permanent Teeth (DMFT) and decayed, missing, and filled deciduous teeth (dmft) indices according to World Health Organization guidelines. On the basis of Angle's classification of malocclusion [Table 1], primary examiner examined the subjects clinically, classifying each subject's occlusion as either class I, class II (division 1 and 2), or class III.[2] Alginate impressions were taken and plaster casts were fabricated within 30 min of taking the impression. Bite wax registration of each study subject was done to facilitate setting up of occlusion on a dental articulator. Analysis of dental casts and extraoral true lateral radiographs was used to make orthodontic diagnosis. The Angle classification was used to assess the sagittal relation. The first molar was used as an indicator tooth.
Table 1: Angle's Classification of Malocclusion2

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The transversal malocclusion, decided by evaluating the relation between mandible and maxilla in the lateral segment, classified as crossbite and scissor bite. The vertical malocclusion was determined by measuring the distance between the incisal edge of the upper and lower front teeth and a distance of (0–5 mm) was considered normal. A higher distance than 5 mm was considered as deep bite, and negative overlapping as an open bite. Under artificial light, using a dental mirror and blunt probes, the patients were also examined for DMFT according to the World Health Organization guidelines.

Statistical analysis

Results were collated and analyzed using standard descriptive statistics. Data from the questionnaire and clinical examinations were analyzed using the Statistical Package of Social Science (SPSS) version 16. Chi-square test of association was used to compare proportions and ratios with the significant level set at P < 0.05 and 95% confidence level.


   Results Top


A total of 140 cleft patients presented in the unit during the period of review, with ages ranging from 1 day to 65 years old. Of this, 74 (52.9%) were male, and 66 (47.1%) were female, giving the male: female ratio of 1.12:1. The mean age of all patients presenting in the period was 6.3 ± 1.02 years, whereas the average age for patients above 6 years who were considered in the analysis for malocclusion was 20.7 ± 1.1 years. The number of patients with cleft lip with or without alveolus involvement only was 66 (47.1%), those with cleft of the lip and palate were 66 (47.1%), and eight (5.7%) patients had isolated cleft palate. Details of the distribution of the clefts by gender and type are as outlined in [Table 2].
Table 2: Distribution of clefts by gender and type

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Analysis for Angle's classification showed that 38 patients (68%) had class I, six patients (12%) had class II, and eight patients (20%) had class III. There were statistically significant differences in the types of clefts and classes of malocclusion observed in this study [Table 3]. Angle's class 1 was statistically higher than other classes (P = 0.000). Class 111 malocclusion was most commonly associated with hard palatal defect. Eight patients (100%) who developed class 111 malocclusion had palatal defect, whereas class 1 was accounted for predominantly by 34 patients (89.5%) with unilateral cleft of lip with or without the involvement of the alveolus.
Table 3: Distribution of Angle's classification of malocclusion according to type of cleft (considering only patients above 6 years of age)

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The prevalence of other orthodontic anomalies observed in this study is shown in [Table 4]. Proclination of the maxillary anterior teeth (increased overjet) was the most common anomaly, occurring in 25 patients (48.1%), whereas increased overbite has the lowest frequency of 2 (3.8%).(P = 0.002).
Table 4: Other Orthodontic Anomalies among the patients surveyed*

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Eighteen out of the 140 children examined had caries experience, giving a prevalence of 12.9% [Table 5]. Of all the teeth examined, 44 teeth (6 permanent and 38 deciduous) had caries. No tooth was filled and none was extracted due to caries. The caries of the deciduous teeth were accounted for by the approximal caries of the upper central incisors, approximal and occlusal caries of the lower first and second deciduous molars (D and E). Caries was statistically significantly higher in deciduous than permanent teeth (P = 0.002)
Table 5: Caries experience among various age groups examined

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   Discussion Top


The purpose of the present study was to assess the malocclusion and caries status of the patients with unrepaired clefts who presented at the National Orthopaedic Hospital Enugu. The ratio of male to female cleft patients in this study was approximately 1.18: 1. This is comparable to the reports of previous studies conducted in some of the Nigerian metropolitan cities such as Jos (1:1.1)[15] and Benin (1.02:1)[16] and a recent study (1.13:1)[3] among the Ibos.

Our observation that cleft lip with or without alveolus involvement had equal prevalence with cleft lip and palate is in contrast with the reports of Jac-Okereke[4] among the Igbos in 2017 and Orkah[15] in Jos which show cleft lip with or without alveolus involvement to be the commonest type of cleft, while the Benin study[16] reported that cleft lip and palate was the most prevalent. In this study, the ratio of cleft lip with or without alveolus involvement: Cleft Palate: Cleft lip and palate was observed as 1:0.12:1 which differs from 26:5:16 observed by Jac-Okereke[3] among the Igbos. Though both studies agree that cleft palate is the least occurring type of cleft. The reason for the difference between our findings and that of JacOkereke may be the smaller sample size of our study.

Cleft lip with or without alveolus involvement alone was most frequently associated with class I malocclusion in the present study. Angle's class 1 was significantly higher than other classes (P = 0.000). Twenty percent had class III, while 12% had class II. This contrasts sharply with the report of Baek et al.[8] in 2002 where class III malocclusion was the most prevalent pattern in their patients, being found in 72.7% of the study population. Vettore et al.[9] also reported class II malocclusion as the most common (58.9%) among the studied Brazillian population, followed by class III (23.2%) and class I (17.9%). Unlike the studies from Korea[8] and Brazil,[9] this study was a prospective one. Patients with Angle's class I malocclusion were less likely to present at orthodontic clinics where their data for a retrospective study would have been pooled. Our study population included all the cleft cases that presented to the cleft unit.

However, in this study, among the patients with cleft involving the hard palate, class III malocclusion was found to be most prevalent. All the patients in this study who developed with class 111 malocclusion had cleft with hard palate involvement. This agrees with the findings of Baek et al.,[8] that the type of cleft significantly influenced the development of a class III malocclusion. Increase in the degree of cleft involvement in the palate increases the predominance of a class III malocclusion. Clefts of the hard palate may be associated with some degree of maxillary hypoplasia.

Among other orthodontic anomalies, proclined teeth (increased overjet) was the most common, occurring in 25 patients (48.1%), followed by tooth rotation and absence (agenesis), each observed in 17 patients (32.7%). In this study, open bite was a more common occlusal anomaly than crossbite, 17.3% versus 15.4%. Similarly, Chopra et al.,[10] reported that anterior open bite and increased overjet were more prevalent among children with clefts, whereas Paradowska-Stolarz and Kawala[1] observed open bite (13–25%) as most common in their study group. However, Sakamoto et al.[17] and Vettore et al.[9] reported crossbite as the most common dental occlusal anomaly in their study population. Higher frequencies of crossbite and open bite have been reported among patients with clefts.[18]

The higher frequency of maxillary overjet reported in the present study may be attributed to the age at which the clefts were repaired. Our study has a high population of late repairs: over 20 years. The patients in the Tokyo[17] and Brazilian[9] studies had lip repair much earlier. It may be that the later the repair the greater the tendency for proclination of the maxillary incisors in cleft lip patients. The pull of the unrepaired orbicularis and other muscles around the cleft lip contributes to the proclination as the patient grows. Furthermore, excessive maxillary overjet in individuals with cleft has been reported[8] to be caused by lip incompetence and failure of the maxillary orbicularis muscle. Timely cleft repair may limit such dental anomaly or disfigurement.

Caries experience in this study was very low by the standard of International Dental Federation.[19] The prevalence of 12.9% observed is lower than the findings of 35.5% prevalence among non-cleft children previously examined in Awgu[20] local government area of Enugu State and 15.5% prevalence found in Enugu metropolis,[21] although their age ranges differ from that of the cleft population. This lower caries prevalence observed in this study contrasts with the findings of Lucas et al.[13] and Kings et al.[14] who observed a higher prevalence of caries in cleft patient than their non-cleft control. There were no restored teeth seen in the study group and this corresponds to non-attendance to the dental clinic also observed among them in spite of the presence of decayed teeth. This is in keeping with the findings of low restorative care observed in previous studies[20],[21] in Enugu, alluding to poor dental awareness. Caries was statistically significantly higher in deciduous than permanent teeth (P = 0.002). This agrees with the finding of King et al.[14] among the Chinese children. Caries experience on teeth increases with time,[20] and more deciduous teeth have stayed longer in the mouth than the permanent teeth in this study.


   Conclusion Top


The high prevalence of malocclusion in these cleft patients emphasizes the need for an interdisciplinary team approach, with timely intervention to improve the structural, functional, and aesthetic outcome of correction of these anomalies. Early inclusion of dental care especially oral hygiene to prevent tooth decays is also important.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Paradowska-Stolarz A, Kawala B. Occlusal disorders among patients with total clefts of lip, alveolar bone, and palate. Biomed Res Int 2014;2014:583416.  Back to cited text no. 1
    
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Oral Health Surveys: Basic Method. 4th ed. Geneva: World Health Organization; 1997. p. 39–46.  Back to cited text no. 2
    
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Jac-Okereke CA, Onah II. Epidemiologic indices of cleft lip and palate as seen among Igbos in Enugu, Southeastern Nigeria. J Cleft Lip Palate Craniofac Anomal 2017;4(Suppl S1):126-31.  Back to cited text no. 3
    
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Iccha K, MaharjanIbrahim HA, Abuaffan AH. Prevalence of malocclusion and orthodontic treatment needs among Down syndrome Sudanese individuals. Braz Dent Sci 2015;18:1-5.  Back to cited text no. 4
    
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Kumar D, Rana M, Dahiya A, Sharma R. Orthodontic camouflage management of a class II malocclusion with impacted canine-A case report. Int J Adv Case Rep 2015;2:1442-4.  Back to cited text no. 5
    
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Gupta A, Gupta A, Bhardwaj A, Vikram S, Gomathi A, Singh K. Assessing Angle's malocclusion among cleft lip and/or palate patients in Jammu. J IntSoc Prev Community Dent 2016;6(Suppl 1):S23-7.  Back to cited text no. 7
    
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Baek SH, Moon HS, Yang WS. Cleft type and Angle's classification of malocclusion in Korean cleft patients. Eur J Orthod 2002;24:647-53.  Back to cited text no. 8
    
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Vettore MV, Sousa Campos AE. Malocclusion characteristics of patients with cleft lip and/or palate. Eur J Orthod 2011;33:311-7.  Back to cited text no. 9
    
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Chopra A, Lakhanpal M, Rao NC, Gupta N, Vashisth S. Oral healthin 4-6 years children with cleft lip/palate: a case control study. N Am J Med Sci 2014;6:266-9.  Back to cited text no. 10
    
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Tereza GP, Carrara CF, Costa B. Tooth abnormalities of number and position in the permanent dentition of patients with complete bilateral cleft lip and palate. Cleft Palate Craniofac J 2010;47:247-52.  Back to cited text no. 11
    
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Zhu WC, Xiao J, Liu Y, Wu J, Li JY. Caries experience in individuals with cleft lip and / or palate in China. Cleft Palate Craniofac J 2010;47:43-7.  Back to cited text no. 12
    
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Lucas VS, Gupta R, Ololade O, Gelbier M, Roberts GJ. Dental health indices and caries associated microflora in children with unilateral cleft lip and palate. Cleft Palate Craniofac J 2000;37:447-52.  Back to cited text no. 13
    
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King NM, Wong WL, Wong HM. Caries experience of chinese children with cleft lip and palate. Cleft Palate Craniofac J 2013;50:448-55.  Back to cited text no. 14
    
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Orkar KS, Ugwu BT, Momoh JT. Cleft lip and palate: The Jos experience. East Afr Med J 2002;79:510-3.  Back to cited text no. 15
    
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Obuekwe O, Akpata O. Pattern of cleft lip and palate [corrected] in Benin City, Nigeria. Cent Afr J Med 2004;50:65-9.  Back to cited text no. 16
    
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Sakamoto T, Sueishi K, Miyazaki H, Katada H, Ebihara T, Kosaka T. Clinical statistical investigation of cleft lip and palate patients aged over 18 years at Department of Orthodontics, Suidobashi Hospital, Tokyo Dental College. Bull Tokyo Dent Coll 2008;49:33-9.  Back to cited text no. 17
    
18.
Sæle P, Østhus E, Šdalen S, Nasir E, Mustafa M. Pattern of clefts and dental anomalies in six-year-old children: A retrospective observational study in western Norway. Acta OdontolScand 2016;75:1-6.  Back to cited text no. 18
    
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Global goals for oral health by the year 2000. Fédération Dentaire Internationale. Int Dent J 1982;32:74-7.  Back to cited text no. 19
    
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Okoye LO, Ekwueme OC. Prevalence of dental caries in a Nigerian Rural Community: A preliminary survey. Ann Med Health Sci Res 2011;1:187-92.  Back to cited text no. 20
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21.
Okoye LO, ChukwunekeFN, Akaji EA, Folaranmi N. Caries experience among school children in Enugu, Nigeria. J Coll Med 2010;15:17-23.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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