ORIGINAL ARTICLE

CLEFT PATTERNS AND OCCLUSION CHARACTERISTICS OF CLEFT PATIENTS ATTENDING TREATMENT IN AN INSTITUTION IN RIYADH, SAUDI ARABIA
Khalid M. Al Balkhi,* BDS, MSc

OBJECTIVE: The purpose of the study was to investigate the distribution of various oral cleft types and the occlusion status of patients with cleft lip and/or palate (CLP) attending dental treatment in the College of Dentistry at King Saud University, Riyadh, Saudi Arabia. METHODOLOGY: The present study was retrospective cross-sectional study done by reviewing the cleft lip and/or palate patients' dental records, and study models. All CLP patients with deciduous, mixed and permanent dentitions were included. A special form was designed exclusively for collecting the required information of every subject. Gender, age, type of cleft and dentition, and occlusion were statistically analyzed using proportional Z test (P<0.05). RESULTS: A total of 165 subjects (109 males (65.5%) and 57 (34.5%) females), constituted the study population. The prevalence among gender was statistically significant (P<0.0005). Among the 165 subjects, 35 (21.2%) were <6 years, 72 (43.6%) were between 7 and 12 years, and 58 (35.2%) were >12 years. Most of the subjects 125 (75.8%) had combined cleft lip and palate (P<0.0005). No statistical difference between the prevalence of unilateral cleft 87 (52.7%) and bilateral clefts 56(33.9%) (P=0.263). In subjects with primary dentition, mesial-step molar relationship was the most common 27(84.4%) (P<0.0005), while class I molar relationship was the most common type in subjects with mixed or permanent dentitions 85(58.2%) (P<0.0005). Combination of posterior and anterior cross-bites were found in the sample; right side 81(29.8%), left side 86(31.6%) and anterior 105(38.6%).. Decreased overbite 101(70.1%) and overjet 98(67.6%) were more commonly found (P<0.000).. CONCLUSION: Various types of CLP were studies and results showed that male subjects were affected more than females. Majority of subjects had the cleft lip and palate type. Anterior and posterior cross-bites, as well as decreased overbite and overject were found in most of the sample. Results indicate the need for interceptive orthodontic in CLP subjects KEYWORDS:Cleft lip, Ckeft plate, Occlusion, Mixed Dentition, Permanent Dentition, J Pak Dent Assoc 2010;19(1):015-018

INTRODUCTION
left lip and palate (CLP) is one of the most common developmental disturbances of orofacial 1-3 structures. The prevalence of cleft lip and/or 4 palate shows a marked racial variation. The reported prevalence varies from 0.19 to 2.69 per 1000 births in different parts of the world.5 Although cleft lip and palate is more frequent in males, cleft palate alone is more in
* Associate Professor in Orthodontics Department of Pediatric Dentistry and Orthodontics College of Dentistry, King Saud University P.O. Box 60169, Riyadh 11545, Saudi Arabia.
Correspondence: Dr. Khalid M.Al Balkhi <kalbalkhi@ksu.edu.sa>

females. In Saudi Arabia, two studies have reported an 6,7 incidence of 0.3 and 2.19 cleft cases per 1000 live births. Worldwide studies have shown that individuals born with cleft lip and/or palate may face different challenges such as anatomical deformities, dental malocclusion, hearing impairment, speech disorder and 8-12 dental health problems. In addition, the development of maxillary arch dimension in CLP patients is significantly different from non-cleft patients.13-14 Furthermore, it has been shown that posterior cross-bite is present in CLP.15 Knowing that CLP is the most common craniofacial anomaly, it is important to study its distribution and the occlusion status of individuals affected. Therefore, the purpose of this study was to
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investigate the distribution of various oral cleft types and the occlusion status of patients with cleft lip and/or palate attending the dental clinics in the College of Dentistry at King Saud University, Riyadh, Saudi Arabia. Findings from this study may highlight patients dental treatment needs and subsequently proper plans for achieving proper oral health in these patients.

87(52.7%)Was more than bilateral 56(33.98%), however it was not statistically significant (P=0.263).In subjects
Table II. Distributor of Cleft by gender and type Cleft Lip Cleft Lip Cleft Alveolar Gender and Palate Palate Cleft Total N% N% N% N% N% Male Female Total * P = 0.000 17 (65.4) 9 (34.6) 26 (15.8) 81 (64.8) 6 (75.0) 4 (66.7) 108 (65.5)

METHODOLOGY:
The present study was a retrospective, cross-sectional study done by reviewing the cleft lip and/or palate patients' dental records and study models. Permission to conduct the study was obtained from the College of Dentistry Research Center. All patients with cleft lip and/or palate having deciduous, mixed, and permanent dentitions were reviewed and included in the study. A special form was designed exclusively for collecting the required information of every subject. The form consisted of demographic information, type of cleft and dentition, and occlusion. Collected data were analyzed using Statistical Package for Social Sciences (SPSS) version 16. Chi square test was utilize to determine the significant difference in the prevalence by gender and age group etc.The P-value less than 0.05 was set for significance.

44 (35.2) 2 (25.0) 2 (33.3) 57 (34.5) 125 (75.8)* 8 (4.8) 6 (3.6 ) 165 (100)

with primary dentition, mesial-step molar relationship was found in most of subjects 27(84.4%) (P<0.0005),
Table III. Distribution of Cleft Palate by Site Cleft Side Right Left Bilateral N 40 47 56 % 24.2 87 (52.7%) NS 28.5 33.9

Mid Palatal 2 1.2 NS = not significant (P = 0.263)

RESULTS:
The distribution of 165 subjects according to gender and age is shown in (Table I). Table I. Gender and Age of Subjects (N=165). Factor Gender Male Female Age Group (years) <6 7-12 >12 Numbers 108 57 35 72 58 % 65.5 34.5 21.2 43.6 < 0.0005 35.2 p-value < 0.0005

while class I molar relationship was the most common type in subjects with mixed and permanent dentitions 85(58.2%) (P<0.0005) (Table IV). Analysis of cross-bite, over-bite and over-jet are shown in (Table V).
Table IV. Primary and Permanent molar relationship % % Type of dentition N within of total type sample Primary molar Terminal Flush 2 Mesial Step Distal Step Permanent molar Class I Class II Class III *, P < 0.0005 27 3 85 28 33 6.2 84.4* 9.4 58.2 19.2 22.6 1.2 16.4 1.8 51.5 17.0 20.0

Overall, males 108(65.5%) were affected approximately twice than females 57(34.5%) (P<0.0005). The combined cleft lip and palate type was found in 125 subjects (75.8%) which was the most common (P<0.0005), followed by 26 subjects (15.8%) having cleft lip alone, while alveolar and isolated clefts were present in 6 (3.6%) and 8 (4.8%) cases respectively (Table II). The distribution of clefts by site is shown in (Table III).Although unilateral cleft
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Approximately half of the sample had anterior and/or posterior cross-bites ranging from 47.4% to 61.4%. No statistical difference was found between the right side 81(29.8%), left 86(31.6%) and anterior 105(38.6%) crossbites within the parameter. Decreased over-bite 101(70.1%) and decreased overjet 98(67.6%) were the most common finding within each related parameter (P<0.0005).

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Table V. Data analysis of Cross-bites

Parameter
Cross-bite Right Left Anterior Over Bite Normal Increased Decreased Overjet Normal Increased Decreased *, P = 0.000

N
81 86 105 20 23 101 26 21 98

% within Parameter
29.8 31.6 38.6 13.9 16.0 70.1 17.9 14.5 67.6
*

% of total sample
47.4 50.3 61.4 12.1 13.9 61.2 15.7 12.7 59.4

DISCUSSION:
This study was conducted to assess the characteristics of the clefts, and the occlusion status of the teeth in CLP patients attending treatment in a teaching institution in Riyadh, Saudi Arabia. This study was a review of the dental records and study models of those patients. Examination of those patients should be the target of future studies. Elaborating on the occlusion status in those patients may help dental planners in their quest to improve treatment services provided. In addition, similar studies should be conducted in other hospitals and dental centers that provide dental treatment for those patients in Saudi Arabia. The overall ratio of male and female clefts reported by Jensen et al16 was 61:39 and by Baek et al17 was 70:30. Compared to the above studies, the result of this study was in agreement with the previous studies showing higher percentage of males to females. This might be due to that social impact in Saudi Arabia as females are not exposed to community compared to males. Another possible explanation is the nature of CLP clinics which receives referrals from all over the country, so traveling might be an obstacle facing the female patients. Therefore, data from the results of the study should be interpreted with caution. Furthermore, less percentage of subjects were less than six years. This might be due to that proper timing of referrals was not followed. Future studies should be conducted nationwide, based on birth registry in all regions. The results showed that no statistical difference between the prevalence of unilaterial and bilaterial clefts, nor between left side and right side clefts. This was in disagreement with other studies,17-20 which reported that the prevalence of unilateral left side clefts were more common than right side clefts. This could be due to that, the present investigated sample was
17

confined to those CLP patients with full deciduous, mixed and permanent dentitions attending dental treatment, thus not representing the whole population of CLP patients. An attempt to explain the predominance of left side has been reported by Jurkewicz and Bryant.21 In this study, majority of primary molars were in the mesial step relationship which had been reflected by high percentage of subjects with class 1 molar relationship. Class III malocclusion was seen in 20% of the subjects. Lower percentage has been reported by Massler and Frankel.22 A higher percentage of class III malocclusion has been reported in Korean cleft patients.17 Future studies should investigate the possible reason for the high percentage of class III molar relationship which might be due to premature extraction of primary molars. Anterior and posterior cross-bite were present in high percentage of subjects in this study. This was in agreement with previous studies.14,15 Although some subjects did not have upper anterior teeth, results showed that decreased overbite and overjet were evident in high percentage. These results indicate that orthodontic treatment is highly needed in cleft patients. A special plan, such as interceptive orthodontic, should be customized for individuals with CLP. Finally, this study is a cross-sectional study based on reviewing dental records and study models of patients attending dental treatment. It should encourage further studies in the field of CLP. The limitation of this study includes, and not limited to, the dependence of the data presented on its availability in subjects' dental records. Future studies should plan to examine patients and record the needed data.

CONCLUSIONS:
Based on the results of this study and within its limitations, it can be concluded that: 1. Male subjects were affected more than females. 2. Most prevalent type of clefts was cleft lip and palate. 3. Most common molar relationship was mesial step in primary dentition and class I in mixed and permanent dentitions. 4. Anterior and posterior cross-bites as well as decreased both over-bite and over-jet were Found in most of sample studied

REFERENCES:
1. 2. 3. Derijcke A, Eerens A, Carels C. The incidence of oral clefts: a review. Br J Oral Maxillofac Surg. 1996; 34:488-494. Tolarova MMJ, Cervenka J. Classification and birth prevalence of orofacial clefts. Am J Med Genet. 1998; 75:126-137. Ankola AV, Nagesh L, Hegde P, Karibasappa GN. Primary dentition status and treatment needs of children with cleft lip JPDA Vol.19 No.1 Jan-Mar 2010

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and/or palate. J Indian Soc Pedod Prev Dent. 2005; 23:80-82. 4. Damle SG. Management of handicapped children in Text Book of Pediatric Dentistry, 2nd Ed. Arya Publications; p. 415, 426. 5. Loffredo LC, Souza JM, Freitas JA, Mossey PA. Oral clefts and vitamin supplementation. Cleft Palate Craniofac J. 2001; 38:7683. 6. Kumar P, Hussain MT, Cardoso E, Hawary MB, Hassanain J. Facial clefts in Saudi Arabia: An epidemiologic analysis in 179 patients. Plas Reconstr Srug. 1991; 88:955-958. 7. Borkar AS, Mathur AK, Mahaluxmivala S. Epidemiology of facial clefts in the central province of Saudi Arabia. Br J Plas Surg 1993; 46:673-675. 8. Bian Z, Du M, Bedi R, Holt R, Jin H, Fan M. Caries experience and oral health behavior in Chinese children with cleft lip and/or palate. Pediatr Dent. 2001; 23:431-434. 9. Ito S, Noguchi M, Suda Y, Yamaguchi A, Kohama G, Yamamoto E. Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients:Supraperiosteal flap technique versus mucoperiosteal flap technique. J Craniomaxillofac Surg. 2006; 34:135-143. 10. Pinto JH, Da Silva Dalben G, Pegoraro-Krook MI. Speech intelligibility of patients with cleft lip and palate after placement of speech prosthesis. Cleft Plate Craniofac J. 2007; 44:635-641. 11. Chanchereonsook N, Samman N, Whitehill TL.The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status: Acritical review. Cleft Platate Craniofac J. 2006; 43:477-487. 12. Chanchareonsook N, Shitehill TL, Samman N.Speech outcome and velopharyngeal function in cleft palate: Comparison of Le Fort 1 maxillary osteotomy and distraction osteogenesisearly results. Cleft Palate Craniofac J.2007;44:23-32.

13. Athanasiou AE, Mazaheri M, Zarrinnia K:Dental arch dimensions in patients with unilateral cleft lip and palate. Cleft Palate J. 1988; 25:139-145. 14. Heidbuchel KL, Kuijpers-Jagtman AM, Kramer GJ, PrahlAndersen B.Maxillary arch dimensions in bilatera lcleft lip and palate from birth until four years of age in boys. Cleft Palate Craniofac J. 1998;35:233-239. 15. Schwartz BH, Long RE Jr, Smith RJ, Gipe DP. Early prediction of posterior cross-bite in the complete unilateral cleft lip and palate. Cleft Palate J. 1984; 21:76-81. 16. Jensen BL, Kreiborg S, Dahl E, Fogh-Andersen P. Cleft lip and palate in Denmark, 1976-1981: Epidemiology, variability, and early somatic development. Cleft Palate J. 1988; 25:258-269. 17. Baek SH, Moon HS, Yang WS. Cleft type and A n g l e ' s classification of malocclusion in Korean cleft patients. Eur J Orthodo. 2002; 24:647-653. 18. Lee YK, Yun WT, Ko SO, Shin HK. A familial survey of degree and etiology in cleft lip and/or palate patients. J Korean A s s o c Oral Maxillofac Surg. 2002; 22:366-374. 19. Fraser FC. The genetic of cleft lip and palate. AM J Hum Genet 1970; 22:336- 352. 20. Wilson ME: A ten-year survey of cleft lip and cleft palate in the South West Region. Br J Plast Surg. 1972; 25:224-228. 21. Jurkewicz MJ, Bryant DL. Cleft lip and palate in dogs: A progress report. Cleft Palate J. 1968; 5:30-36. 22. Masler M, Frankel JM. Prevalence of malocclusion in children age 14 to 18 years. AM J Orthod 1951; 37:751-768.

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