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ORIGINAL RESEARCH Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 2  |  Page : 82-86
Root development of permanent lateral incisor in cleft lip and palate children: A radiographic study


Dept. of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India

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Date of Submission25-Aug-2005
Date of Decision08-Jan-2007
Date of Acceptance22-Jan-2007
 

   Abstract 

Objective: The objective of this study was to compare the root development of lateral incisor on the cleft side with the root development of its contralateral tooth in cleft lip and palate children. Setting: Cleft lip and palate wing, Meenakshi Ammal Dental College and Hospital, Chennai, South India. Materials and Methods: A sample of 96 orthopantamograms of patients with unilateral or bilateral cleft lip and/or cleft palate was selected, regardless of sex and race. Main Outcome Measure: Orthopantamograms were analyzed for root development of lateral incisor on the cleft and noncleft side. Associated anomalies like hypodontia, supernumerary teeth, malformed lateral incisors and root development of canine, if present, were recorded. Findings and Conclusions: Root development of permanent lateral incisor was delayed on the cleft side compared to the noncleft side. There was a statistically significant relationship between levels of root development of lateral incisors on the cleft side within the different study groups ( P < 0.05). Incidence of hypodontia increased in proportion to cleft severity. Frequency of missing second premolars, supernumerary teeth and malformed lateral incisors increased in cleft lip and palate patients. Root development of canine showed a slight delay on the cleft side when compared to the canine on the noncleft side.

Keywords: Cleft lip and palate, hypodontia, permanent lateral incisor, root development

How to cite this article:
Amarlal D, Muthu M S, Siva Kumar N. Root development of permanent lateral incisor in cleft lip and palate children: A radiographic study. Indian J Dent Res 2007;18:82-6

How to cite this URL:
Amarlal D, Muthu M S, Siva Kumar N. Root development of permanent lateral incisor in cleft lip and palate children: A radiographic study. Indian J Dent Res [serial online] 2007 [cited 2020 Sep 27];18:82-6. Available from: http://www.ijdr.in/text.asp?2007/18/2/82/32426
Cleft lip and palate is a common congenital anomaly. Children with cleft lip and palate have many problems, and the complexity of these problems requires numerous health care practitioners to form a cleft team. This multidisciplinary cleft lip and palate team is responsible for the patient's medical and general development, facial esthetics and psychological well-being, hearing and speech development.

Numerous dental anomalies occur with cleft lip and palate, namely, hypodontia, supernumerary teeth, microdontia, fused teeth, ectopic eruption, posterior crossbites, pseudoprognathism and the like. These defects may be attributed to the cleft itself or to the early surgical correction of the defects.

Ranta in 1972[1] reported that congenital absence of the cleft-side permanent lateral incisor is the most common finding in children with cleft lip, cleft palate or both. Supernumerary teeth in the cleft region is the second most common anomaly, followed by hypodontia. Hypodontia of the maxillary and mandibular premolars is more frequent than other congenitally missing teeth outside the cleft area in subjects with cleft lip, cleft palate or both.

Delayed eruption of permanent teeth in cleft lip and/or cleft palate patients was reported by Bailit et al. in 1968.[2] Prahl and Anderson in 1979[3] reported delayed dental development in boys alone until the age of 9 years. Loevy and Aduss in 1988[4] have reported precocious development of teeth in boys with cleft.

Ribiero et al. in 2002[5] were the first to compare the root development of permanent lateral incisor on the cleft side with its contralateral tooth in subjects with unilateral cleft lip and palate. They found that the root development of permanent lateral incisor on the cleft side was delayed when compared with its contralateral tooth. In a study by Dewinter et al. in 2003,[6] hypodontia of lateral incisor was found in 58.6% of the patients. Hypodontia of teeth outside the cleft area was found to be 27.2%. Ribiero et al. in 2003[7] reported that congenital absence of lateral incisor on the cleft side was observed in 49.8% of the patients. The cleft side permanent lateral incisor was present in 50.2% and was more commonly located at the distal (76.5%) than the mesial (23.5%) side of the cleft. Hypodontia outside the cleft area was 20.7% on the cleft side and 15.7% on the noncleft side. Supernumerary teeth were observed in 6.4% of the sample.

The purpose of this study was to compare the root development of the lateral incisor on the cleft side to that on the noncleft side in south Indian children. The incidences of other dental anomalies like missing teeth, supernumerary teeth and malformed teeth were recorded. The difference between the development of canine on the cleft side and that on the noncleft side was also noted.


   Materials and Methods Top


This study was carried out in the cleft lip and palate wing of the Oral and Maxillofacial Surgery Department in Meenakshi Ammal Dental College, Chennai, India. Three hundred orthopantamograms were evaluated from the data bank of the cleft lip and palate wing. Among the 300 orthopantamograms, 100 orthopantamograms of children in the 6-16 years age group were selected. The selection criteria included the presence of unilateral or bilateral cleft lip and/or cleft palate. Subjects were not excluded based on sex or ethnic background. Four orthopantamograms were excluded because of lack of clarity. The remaining 96 orthopantamograms were checked under adequate illumination for the stage of development of lateral incisor and canine on the cleft side and noncleft side based on Nolla's stages.[8] Associated anomalies like hypodontia of lateral incisors, hypodontia of premolars and supernumerary teeth were also recorded. The presence of permanent lateral incisor on the cleft side was determined by a criterion established by Damante et al. in 1973,[9] according to which a lateral incisor is defined as a single tooth in the vicinity of the cleft, in the mesial or distal side, accepting any tooth morphology; or as a tooth in the mesial side with another one in the distal side, which was considered as a supernumerary tooth.

A proforma was prepared, in which the name, age, sex, type of cleft and Nolla's stages of development of lateral incisor and canine were entered in separate columns. The numerical value corresponding to the Nolla's stage of development for lateral incisor was entered both on the cleft and the noncleft side. In subjects where there was difference in the development of canine on the cleft side and noncleft side, such difference was noted and those values were recorded in the pro forma. Other associated anomalies like hypodontia of premolars, supernumerary teeth and malformed incisors were also recorded. Once this data was collected, it was divided into four groups as follows:

Group 1 - Unilateral cleft lip and alveolus

Group 2 - Bilateral cleft lip and alveolus

Group 3 - Unilateral cleft lip and palate

Group 4 - Bilateral cleft lip and palate

This data was sent for statistical analysis. The assessment of all orthopantamograms was done by a single examiner. To assess the accuracy of the examiner, 15 randomly selected orthopantamograms were reassessed and statistically analyzed.

  1. Spearman rank test was done for correlation analysis of cleft and noncleft scores.
  2. Pearson's Chi-square test was used to calculate the ' P ' value for associated anomalies.
  3. One-way ANOVA was used to calculate the mean values of age of different study groups.
  4. Pearson's Chi-square test and Fisher's exact test were used to find out the distribution of missing teeth.
  5. Kruskal-Wallis one-way ANOVA and Mann-Whitney U test were used to calculate the mean cleft scores.
  6. Intra-examiner variability was assessed using intra-class correlation coefficient.



   Results Top


Comparison between the four groups was done under the following parameters:

Age, sex, scores for cleft side and noncleft side, hypodontia of lateral incisor and associated anomalies. There was no significant difference between mean ages of different study groups ( P = 0.90).

Mean, standard deviation and test of significance of mean values of cleft-side Nolla's score for lateral incisor in different study groups were as follows - Group 1: 5.8 ± 3.5, Group 2: 2.0 ± 2.2, Group 3: 3.6 ± 3.4, Group 4: 3.9 ± 4.1.

Kruskal-Wallis one-way ANOVA test was used to calculate the ' P ' value. Mann-Whitney U test with Bonferoni correction method was employed to identify significant groups at 5% level.

There was no significant difference in mean cleft side scores between different study groups at 5% level. Mean, standard deviation and test of significance of mean values of noncleft side for lateral incisor in different study groups were as follows - Group 1: 8.9 ± 1.9, Group 3: 8.7 ± 1.9.

Kruskal-Wallis one-way ANOVA test was used to calculate the ' P ' value. Mann-Whitney U test with Bonferoni correction method was employed to identify significant groups at 5% level.

Mean, standard deviation and test of significance of mean values of cleft-side Nolla's score for canine in different study groups were as follows - Group 1: 7.4 ± 0.9, Group 3:

7.2 ± 1.3 of the cleft, compared with its contralateral tooth, in the south Indian population attempted to determine the differences in the root development in cleft lip and palate

Mann-Whitney U test was used to calculate the ' P ' value. There was no significant difference in the mean cleft-side canine scores between Groups 1 and 3 ( P = 0.78).

Mean, standard deviation and test of significance of mean values of noncleft side for canine in different study groups were as follows - Group 1: 8.6 ± 0.5, Group 3: 8.3 ± 1.2.

Mann-Whitney U test was used to calculate the ' P ' value. There was no significant difference in mean noncleft side canine scores between Groups 1 and 3 ( P = 0.63).

Correlation analysis of cleft and noncleft scores for lateral incisor and canine, distribution of missing teeth supernumerary teeth, and malformed lateral incisors, and repeatability analysis are to tabulated [Table - 1],[Table - 2],[Table - 3],[Table - 4],[Table - 5],[Table - 6],[Table - 7],[Table - 8].


   Discussion Top


This study of lateral incisor root development in the vicinity of the cleft, compared with its contralateral tooth, in the south Indian population attempted to determine the differences in the root development in cleft lip and palate patient.

Demerijian et al. in 1973[10] observed that mechanisms controlling dental development are independent of somatic and sexual maturity and seem to be highly influenced by the same etiological factors as the cleft. In this study, the cleft-side lateral incisor, if present, was compared for its root development with the noncleft side using Nolla's rating system. The degree of root development on the cleft side and noncleft side was similar in both the sexes. This is in agreement with studies done by Solis et al. in 1998[11] and Ranta et al. in 1972.[1] There was a statistically significant difference in the mean values between the cleft and the noncleft sides, indicating a delay in the root development for the cleft side lateral incisor [Figure - 1]. This asymmetry has been noted by Ranta in 1972,[1] Solis et al. in 1998[11] and also in a similar study by Ribiero et al. in 2002.[5] According to Solis et al. in 1998[11] and Peterka et al. in 1993,[12] this delay in root development occurred because of the same factors that are responsible for the formation of cleft. Other factors have also been proposed to account for this delay, including surgery around the cleft side according to Ranta in 1972,[1] nutritional factors according to Ranta in 1972[1] and Solis et al. in 1998,[11] a prenatal insult interacting with a poorly buffered genotype according to Bailet et al. in 1968[2] and lack of bone support according to Peterka et al. in 1996.[12]

In this study, the root development of canine showed a slight delay on the cleft side when compared to the canine on the noncleft side.

There was statistically significant difference when hypodontia rates of the permanent lateral incisor for the cleft and noncleft sides were compared [Figure - 2]. Proportion of missing teeth on the cleft side in Group I was 29%, and on the noncleft side it was 0%. Proportion of missing teeth in Group 3 on the cleft side was 58.7%, and on the noncleft side it was 2.2%. Proportion of missing teeth in Group 2 and Group 4 was 80.0% and 64.3% respectively. This is in agreement with a similar study done by Ribiero et al. in 2003.[7] This hypodontia can be attributed to any of the following factors: the vicinity of the cleft according to Jiroutova and Mullerova in 1994[13]; the deficiency of blood supply, either congenital or secondary to surgery, according to Vichi and Franchi in 1995[14] or even deficiency in the mesenchymal support according to Tsai et al. in 1998.[15] Brattstrom and McWilliams in 1989[16] reported that the prevalence of hypodontia increases in proportion to cleft severity. In our study, the proportion of missing teeth in Group 3 and Group 4 was higher when compared to Groups 1 and 2.

The absence of fusion between the maxillary and medial nasal processes, possibly because of a deficiency of mesenchymal mass, could result in the cleft lip, cleft palate or both, and it is probable that the lateral incisor odontogenic potential comes from both these regions. This hypothesis, supported by Tsai et al. in 1998,[15] could explain the hypodontia of lateral incisor, its location at the distal or mesial side and the presence of a supernumerary tooth.

In our study, the frequency of missing premolars is 7.2%, which is slightly lower compared with 18% missing premolars reported by Shapira et al. in 1999[17] in their sample of cleft lip and palate individuals.

The frequency of supernumerary teeth was found to be 5.2% and was equally distributed among the four groups [Figure - 3]. The frequency of malformed lateral incisors was 21.8% and was found to be more in Group 1. This is because Group 1 is the least severe of the four groups.

Knowledge of developmental delay of lateral incisor on the cleft side is of value for determining the secondary bone graft placement on the basis of degree of root development, as proposed by Solis et al. in 1998.[11] Because of the higher frequency of missing lateral incisors and second premolars found in cleft lip and palate children, it is important to determine at an early age the presence or absence of all permanent teeth and formulate an early treatment plan.

 
   References Top

1.Ranta R. A comparative study of tooth formation in the permanent dentition of Finnish children with cleft lip and palate. An orthopantomographic study. Proc Finn Dent Soc 1972;68:58-66.  Back to cited text no. 1    
2.Bailit HL, Doykos JD, Swanson LT. Dental development in children with cleft palates. J Dent Res 1968;47:664.  Back to cited text no. 2    
3.Prahl-Andersen B, Kowalski CW, Heyendaal PH, editors. A mixed longitudinal interdisciplinary study of growth and development. Academic Press: New York; 1979.  Back to cited text no. 3    
4.Loevy HT, Aduss H. Tooth maturation in cleft lip, cleft palate or both, Cleft Palate J 1988;25:343-7.  Back to cited text no. 4    
5.Ribeiro LL, das Neves LT, Costa B, Gomide MR. Dental development of permanent lateral incisor in complete unilateral cleft lip and palate. Cleft Palate Craniofac J 2002;39:193-6.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Dewinter G, Quiryen M, Heidbuchel K, Verdonck A, Willems G, Carels C. Dental abnormalities, bone graft quality and periodontal conditions in patients with unilateral cleft lip and palate at different phases of orthodontic treatment. Cleft Palate Craniofac J 2003;40:343-9.  Back to cited text no. 6    
7.Lourenco Ribeiro L, Teixeira Das Neves L, Costa B, Ribeiro Gomide M. Dental anomalies of the permanent lateral incisors and prevalence of hypodontia outside the cleft area in complete unilateral cleft lip and palate. Cleft Palate Craniofac J 2003;40:172-5.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Nolla CM. The development of the permanent teeth. J Dent Child 1960;27:245-66.  Back to cited text no. 8    
9.Damante JH, Souza Freitas JA, Moraes N. Anomalias de numero na area da fissura em portadores de mal formacao congenitas labio palatias. Estomatol Cul 1973;7:88-97.  Back to cited text no. 9    
10.Dermijian A, Goldstein H, Anner JM. A new system of dental age assessment. Hum Biol 1973;45:211-27.  Back to cited text no. 10    
11.Solis A, Figueroa AA, Cohen M, Polley JW, Evans CA. Maxillary dental development in complete unilateral alveolar clefts. Cleft Palate Craniofac J 1998;35:320-8.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Peterka M, Tvrdek M, Mullerova Z. Tooth eruption in patients with cleft lip and palate. Acta Chir Plast 1993;35:154-8.  Back to cited text no. 12  [PUBMED]  
13.Jiroutova D, Mullerova Z. The occurrence of hypodontia in patients with cleft lip and palate. Acta Chir Plast 1994;36:53-6.  Back to cited text no. 13    
14.Vichi M, Franchi L. Abnormalities of the maxillary incisors in children with cleft lip and palate. ASDC J Dent Child 1995;62:412-41.  Back to cited text no. 14  [PUBMED]  
15.Tsai TP, Huang CS, Huang CC, See LC. Distribution patterns of primary and permanent dentition in children with unilateral complete cleft lip and palate. Cleft Palate Craniofac J 1998;35:154-60.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Brattstrom V, McWilliams J. The influence of bone grafting age on dental abnormalities and alveolar bone height in patients with unilateral cleft lip and palate. Eur J Orthod 1989;11:351-8.  Back to cited text no. 16    
17.Shapira Y, Lubit E, Kuftinec MM. Congenitally missing second premolars in cleft lip and cleft palate children. Am J Orthod Dentofac Orthop 1999;115:396-40.  Back to cited text no. 17    

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Correspondence Address:
Deepti Amarlal
Dept. of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.32426

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    Figures

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