Assessing Angle's malocclusion among cleft lip and/or palate patients in Jammu.

OBJECTIVE: The study was conducted to examine the patients with abnormalities of cleft lip and/or palate and its association with different types of malocclusion.
MATERIALS AND METHODS: This descriptive study was done among 168 patients with abnormalities of cleft lip and/or palate. Angle's classification of malocclusion was applied for assessment of occlusion as Class I, Class II, and Class III. The types of oral clefts classification such as cleft lip unilateral and cleft lip bilateral, cleft palate (CP), unilateral cleft lip with palate (UCLP) and bilateral cleft lip with palate (BCLP) was considered. Chi-square test was applied to analyze the data at P < 0.05.
RESULTS: The study showed different categories of clefts patients as cleft lip (81), CP (31), and both cleft lip and palate (53). The occurrence of unilateral cleft lip (44) was maximum among the sample followed by UCLP (39), and bilateral cleft lip (31). Maximum subjects with Class II (10.7%) and Class III (4.9%) malocclusion were seen with unilateral cleft lip deformities. None of the patients with UCLP had Class III malocclusion.
CONCLUSION: Cleft lip was the most commonly observed deformity and high frequency of Class II and III malocclusion was evident. Therefore, patients with such abnormalities should be screened timely.

INTRODUCTION

Patients with deformities may be physically, socially, or mentally challenged and comprise more marked oral health-related problems, either because of their authentic disability or because of associated medical conditions.[1] The incorporation of individuals with oral cleft problems into civilization needs an interdisciplinary approach.[2]

The occurrence of cleft lip and/or palate (CLP) is most frequent congenital defect, next to osteomuscular and nervous system anomalies.[3] Its incidence has been mentioned as 0.18 per 1000 live births around the world.[4] The World Health Organization (WHO, 1997) reported that CLP is a major dental health issue as it affects psychologically, esthetically, and functionally. Infect, in India alone, a child is born with a cleft after every 2 min.[5]

Children with CLP face clinical problems which include delayed eruption of teeth, attrition, occlusal interference, intrusion with tongue leading obscurity in mastication, temporomandibular joint dysfunction, periodontal problems and increased susceptibility to dental caries. In spite of this, these patients and their parents give more significance only to the surgical correction of clefts abnormalities and ignore the other oral health problems including functional disorder such as malocclusion.[67]

Malocclusion is irregularity which leads to disfigurement hampering the function of teeth, and this disfigurement or imperfection is likely to be an impediment to the patient's physical or emotional comfort.[8] Malocclusion compromises the health of oral cavity and also can lead to social problems to affected patients.[9] It is the second commonest dental disease in patients after caries.[10]

Orthodontic problems have been correlated with psychosocial distress, deprived periodontal conditions, and weak masticatory functions.[11] There is also evidence that certain features such as overbite, unprotected incisors, and impacted teeth may negatively affect the prolonged existence of dentition.[12]

Malocclusions and cleft abnormalities have been described in many books.[38] However, there are few studies that have associated malocclusions with oral clefts.[1314] Sakamoto et al., in 2008 rated 8.6% crossbites in CLP cases and Vallino et al. observed prevalence of malocclusions in 62% children with oral clefts.[14] Baek et al. reported occurrence of malocclusion in 76.3% and 42.1% patients with a trans-foramen incisor cleft and preforamen incisor cleft, respectively.[15] Therefore, it is expected that these patients having different types of oral clefts present differences in the malocclusions. Thus, this present study aimed to evaluate the type of malocclusions in patients with CLP.

MATERIALS AND METHODS

The present cross-sectional investigation was carried out during April 2014 to September 2015 at a Dental Institute in Jammu, India. The sample was collected from different hospitals in the city using multistage random sampling. A total of around 200 patients with abnormalities of cleft lip and/or palate were observed and out of which 168 finalized according to the study criteria. The subjects who have been treated and undergoing management of cleft lip and/or palate with complete permanent dentition only were included in this study and the patients undergoing orthodontic treatment were excluded from the study.

Official permission to conduct the survey was obtained from the Institute and an informed consent was taken from the participants.

The demographic details of the subjects including age, sex, type of the cleft lip and/or palate were recorded. The age of patients ranged from 13 to 18 years. The total number of male participants was 77 and females were 91. Clinical examination was done by an expert examiner of from the Orthodontic Department according to the classification of malocclusion given by Angle and the relationship between the first permanent maxillary and mandibular molar was considered as Class I, Class II (division 1 and 2), and Class III.[16] The intra-examiner as well as inter-examiner reliability of the examiners was done. To assess the occlusion level, impressions were taken with alginate (Manufacturer Exporters, Gurgaon) and each study subject was asked to bite a wax (Shiva Products, Vasai) to set up occlusion and plaster casts were fabricated.[15] These casts were examined in the clinic to acquire malocclusion measurements.

Information was obtained regarding the types of oral clefts from the patient's records or by examination. Different types of clefts were noticed such as cleft lip unilateral and Cleft lip bilateral, cleft palate (CP), unilateral cleft lip with palate (UCLP) and bilateral cleft lip with palate (BCLP).

Data analysis

The data was collected and analyzed by SPSS 16.0 software (SPSS, Chicago, IL, USA). Chi-square test was applied to analyze the statistics. The level of significance in this analysis was set at P < 0.05.

RESULTS

The total number of subjects with cleft lip and/or palate was 168, which was further assorted into different types as cleft lip (84), CP (31) and cleft lip and palate (53) patients as mentioned in Graph 1. The occurrence of unilateral cleft lip (44) was maximum among the sample followed by UCLP (39), and bilateral cleft lip (31). However, the prevalence of bilateral CP was minimum (15), as referred in Graph 2. Further, the graph elaborates the relationship of the type of cleft with gender, wherein boys were observed having higher frequency of unilateral cleft lip (25), bilateral CP (8), and unilateral CLP (22) and girls showed higher values in rest of the cleft lip and/or palate aberrations.

Graph 1

Different types of clefts

Graph 2

Cleft lip and/or palate deformities according to gender

The data revealed Angle's Class I malocclusion among 65.4% of the subjects followed by Class II (25.0%) and Class III (9.6%) as shown in Table 1. The type of malocclusion was also correlated with gender and mostly girls were found with more number of malocclusions of Angle's classification as mentioned in Table 2.

Table 1

Prevalence of Angle's malocclusion classification according to age

Table 2

Prevalence of Angle's malocclusion classification according to gender

When category of cleft lip and/or palate abnormalities were related to Angle's classification of malocclusion, maximum cases of Class II (10.7%) and Class III (4.9%) malocclusion were seen with unilateral cleft lip conditions. Bilateral cleft lip and unilateral CLP showed 7.1% and 3.0% patients of Class II malocclusion, respectively. Least subjects with Angle's Class I (3.6%) and Class II (0.6%) malocclusion were observed in bilateral CLP deformity, and none of the patient with unilateral CLP had Class III malocclusion cases illustrated in Table 3.

Table 3

Association of cleft lip and/or palate deformities with types of malocclusion

DISCUSSION

Clefts are frequent birth defects and are mainly accompanied by a variety of malformations, such as disturbances in facial appearance along with skeletal disorders that includes malocclusions.[17] Oral clefts mainly comprise lips, alveolar arches, and hard and soft palate.

In this study, the ratio of cleft lip: CP: Cleft lip palate was observed as 84:31:53. However Fogh-Andersen reported it as 1:1:2.[18] and Jensen et al., as 34:39:27.[19] A wide variation has also been reported among Koreans.[2021]

In our study, unilateral clefts occurred significantly more often than bilateral clefts (approximately 3:1), which was in agreement with previous studies.[1922] Jurkiewicz and Bryant recommended that the (unilateral) left-side preponderance of cleft development was due to the right side of the embryo's head which obtains somewhat greater supply of blood due to the elevated blood pressure from right internal carotid artery.[23]

The data also observed overall ratio of boys and girls in relation to clefts, which was almost 1:1. However, Jensen et al.[19] observed the ratio of male to female as 3:1. Similarly most of the previous studies were in contrast to the present data, showing higher incidence of cleft defects in male counterparts.[2425] Cooper et al. stated the proportion of males to females as 1:1.3 in CP and 1.6:1 for cleft lip.[26] But Meskin et al.[27] hypothesized that CP was additionally frequent among females as the secondary palate of female fuses later as compared to males, therefore, females were more commonly affected. Furthermore, Burdi and Silvey confirmed this assumption experimentally with histologically sectioned human embryos.[28]

The present study also observed that maximum cases of Angle's Class II (10.7%) and Class III (4.9%) malocclusion were associated with unilateral cleft lip patients and minimum subjects with Class I (3.6%) and Class II (0.6%) malocclusion were observed in bilateral CLP patients as the prevalence of these patients was fewer comparatively. Baek et al. found a similarity between types of malocclusion and diverse classification of oral clefts.[15] On the other hand, some practical issues, counting differences according to malocclusion criteria, age range of participants, and surgical procedures of oral cleft, limit the comparisons between studies.

Hongal et al., in their study, mentioned that patients with cleft lip and/or palate abnormality (8.92%) scored a Dental Anxiety Index of 31-35 (severe malocclusion).[29] Shrestha et al. found that overjet had a significant difference in cases of BCLP while major difference was observed with overbite in UCLP condition.[7]

Chopra et al. also stated that the occurrence of malocclusion were higher in patients with oralcleft deformities. This anomaly could be possibly related to the unusual tongue movement or a poor swallow reflex.[30] Additionally, it was observed that the frequency of developmental defects of enamel were more among these patients than those without clefts.[31]

The decay percentage of teeth and premature loss of deciduous teeth that is more commonly found in cleft patients, affects to relocation of teeth, and deteriorates occlusion.[17] Furthermore, investigations on fetuses as well as dental casts in a group of postnatal sample have concluded that the features that led to cleft deformities are also responsible for the tooth defects.[32] The present study has limited sample size and few knowledge regarding the lack of information relating to the time of surgical restore and therefore more research is required on large sample of oral clefts and to follow them regularly at primary, mixed, and permanent stages of dentition.

CONCLUSION

The study evidenced increased dominance of Class II and III malocclusion in patients having cleft lip and/or palate deformities and orthodontic treatment needs vary among them. Henceforth, such patients should be screened in early phases of life to avert such complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.