Orthodontic problems in repaired cleft lip and palate patients seen in a Federal Teaching Hospital in Gombe, North Eastern Nigeria

Elfleda Angelina Aikins; Olugbemi Benedict Akintububo

doi:10.4103/nnjcr.nnjcr_7_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 10 | Issue : 17 | Page : 30-33

Orthodontic problems in repaired cleft lip and palate patients seen in a Federal Teaching Hospital in Gombe, North Eastern Nigeria

Elfleda Angelina Aikins¹, Olugbemi Benedict Akintububo²
¹ Department of Child Dental Health, Faculty of Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
² Department of Oral and Maxillofacial Surgery, Federal Teaching Hospital, Gombe, Gombe State, Nigeria

Date of Submission	23-Apr-2020
Date of Decision	21-Sep-2020
Date of Acceptance	07-Oct-2020
Date of Web Publication	24-Apr-2021

Correspondence Address:
Dr. Elfleda Angelina Aikins
Department of Child Dental Health, Faculty of Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers State
Nigeria

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/nnjcr.nnjcr_7_20

Abstract

Background: Clefts of the orofacial complex are the second most prevalent birth defects anomalies. Management of children born with clefts is multidisciplinary with oral surgeons and orthodontists playing major roles. Objective: The aim of this study was to ascertain the occlusal anomalies in patients who had undergone cleft lip and palate repair. Methods: Data was collected from participants using a pretested anonymous structured questionnaire. An examination of their occlusions was carried out on the same day. All findings were recorded on a data sheet. Data were analyzed using the Statistical Package for the Social Sciences 20.0, and frequency tables of variables were generated. Significance was determined at a 95% confidence interval, and statistical significance was set at P < 0.05. Results: Twenty-four (75.0%) patients presented with at least one incisor with a positive overbite, 21 (65.63%) with a positive overjet, 16 (50.0%) with anterior tooth rotations, 13 (40.63%) had crossbite and edge-to-edge bite, and 8 (25.0%) had anterior tooth displacements. There was no recorded crossbite among patients with repaired cleft palate only. More than half of the participants 17 (53.8%) with anterior crossbite had repaired cleft lip and palate. Conclusion: Almost all the patients had untreated occlusal anomalies, and we are, therefore, recommending that an orthodontist be included in all Smile Train Teams in Nigeria to ensure total rehabilitation of cleft lip and palate patients.

Keywords: Gombe, Nigeria, occlusal anomalies, repaired cleft, teaching hospital

How to cite this article:
Aikins EA, Akintububo OB. Orthodontic problems in repaired cleft lip and palate patients seen in a Federal Teaching Hospital in Gombe, North Eastern Nigeria. N Niger J Clin Res 2021;10:30-3

How to cite this URL:
Aikins EA, Akintububo OB. Orthodontic problems in repaired cleft lip and palate patients seen in a Federal Teaching Hospital in Gombe, North Eastern Nigeria. N Niger J Clin Res [serial online] 2021 [cited 2023 Sep 22];10:30-3. Available from: https://www.mdcan-uath.org/text.asp?2021/10/17/30/314605

Introduction

The progress of orthodontic treatment for cleft lip and palate patients has been slow, but considerable progress has been made particularly over the past 60 years. The American Cleft Palate Association was formed in 1943 as a result of the need to promote a team approach as well as the inclusion of orthodontists in the interdisciplinary care of patients with clefts.^[1] This resulted in the participation of orthodontists in cleft teams and the resultant discovery of severe three-dimensional growth disturbances in patients with repaired clefts of lip and palate due to scar tissue formation after surgery.^[2] Presurgical orthopedics^[3] and primary bone grafting^[4] became increasingly popular in the 1960s, though there were some reservations regarding the advantages of these techniques. At present, the orthodontic management of patients with complete clefts has evolved to become a unique subspecialty involving special training.^[5]

Clefts of the orofacial complex are the second most prevalent birth defects and anomalies.^[6] Management of children born with clefts is multidisciplinary with oral surgeons and orthodontists playing major roles. Diagnosis of cleft lip can be made as early as 16 weeks in utero using ultrasound.^[7] The orthodontists' role in the rehabilitation of cleft lip and palate patients begins at birth with the use of presurgical orthopedics.^[8] Patients with cleft palate are provided with feeding plates or feeding bottles with specialized nipples by the orthodontist to enable them to suck properly in order to thrive and be of adequate weight before undergoing surgical repair of the cleft.^[9] Subsequently, maxillary expansion alone may be carried out in the primary dentition and/or maxillary expansion with maxillary protraction in the mixed dentition.^[10] After which, secondary alveolar bone grafting is carried out in the area of the cleft.^[11] Definitive orthodontic treatment to correct occlusal anomalies is carried out in the mixed and permanent dentition.

Surgical repair of orofacial clefts affords the patients an acceptable facial appearance, improved speech, and ability to feed. Many of them are completely satisfied with their much improved facial esthetics after surgery.^[12] However, some dental and occlusal anomalies still exist which as they grow older diminish their quality of life. Cleft patients may have missing and/or displaced teeth, narrow maxillary arches and anterior or posterior crossbites. As a result of which both facial and dental aesthetics as well as function are compromised.

The occlusal anomalies are managed in developed countries by carrying out orthodontic treatment in the permanent dentition in order to achieve acceptable dental esthetics and function.^[13] However, in developing countries like Nigeria due to reduced awareness as well as a lack of funds and skilled workforce, many of these patients do not benefit from required orthodontic treatment. It is imperative that the cleft lip and palate patient in our environment be fully rehabilitated. To be able to do so, our study will provide information and enlightenment on the orthodontic problems of patients with repaired cleft lip and palate. Some cleft teams in Nigeria have not yet included the orthodontist, so this study will go a long way to bring the understanding of the place of the orthodontist in not only the presurgical but also postsurgical management of patients with orofacial clefts.

It has been noted in Nigeria that due to scarcity of funds, many cleft lip and palate patients are treated with surgery alone even though there is an obvious requirement for further management.^[14] There is also the difficulty of attendance at recall visits due to satisfaction with their appearance after the cleft lip is repaired.^[14],[15] This may be the reasons why there are few studies on orthodontic problems of cleft repairs in the literature.

This study will enable us to make informed recommendations to the appropriate authorities for the comprehensive treatment of children born with orofacial clefts. It will also enable us to seek for much justified funding for the orthodontic management of patients with repaired orofacial clefts. Smile Train Organization of the United States of America is now funding as well as leading the way in Africa to incorporate the orthodontist in the management of orofacial clefts. To justify this, the aim of our study was to ascertain the occlusal anomalies in patients who have undergone cleft lip and palate repair.

Material and Methods

All patients who had cleft lip and palate repair at the Federal Teaching Hospital, Gombe, North Eastern Nigeria, between January 1, 2016, and December 31, 2016, were recalled. Ethical approval was obtained from the Ethics and Research Committee of the Federal Teaching Hospital, Gombe. Written consent was also sought and obtained from the patients or the caregivers. Out of 109 patients, only 32 patients (29.4%) responded and were examined for occlusal anomalies.

The data were collected using a pretested anonymous structured questionnaire. Oral examinations were carried out with the use of gloves, facemasks, and tongue depressors which were discarded after each use. Section A of the questionnaire captured sociodemographic data; Section B supplied information on participant's postsurgical esthetics, function, and speech, and Section C provided information on the occlusion of the participants. An examination of their occlusions was carried out on the same day the questionnaire was returned.

The findings were recorded on a datasheet and entered into a computer, and statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) software version 20.0 (SPSS, Chicago, IL, USA). Frequency tables of variables were generated, significance was determined at a 95% confidence interval, and statistical significance was set at P < 0.05.

Results

A total of 32 patients participated in the study, with a mean age of 6.14 + 2.80 years. There were 14 (43.75%) females and 18 (56.25%) males.

Fifteen (46.87%) patients had surgical repair of cleft lip alone, 13 (40.62%) patients had surgical repair of both cleft lip and palate. Two (6.25%) patients had both alveolus and palate repaired, also 2 (6.25%) patients had surgical repair of cleft lip alone. About three-quarters 23 (71.87%) of the participants were satisfied with their appearances after the surgeries. The participants also had improved oral function as 31 (96.75%) of them said that they could eat properly and 26 (81.25%) of the studied population indicated that they could speak legibly. More than half of the participants 19 (59.37%) were not happy with the arrangement of their teeth after the surgeries and wanted to change the arrangement. However, they did not know the right professional to do this for them as 20 (62.50%) indicated “doctor” and only 1 (3.12%) patient knew that teeth are rearranged by a dentist [Table 1].

Table 1: Participants' dental esthetics and function

Click here to view

[Table 2] shows a cross tabulation of type of cleft repair and level of satisfaction of the participants/caregivers. There were high levels of satisfaction, and the highest level of dissatisfaction was found among those who had only lip repaired 5 (33.30%).

Table 2: Cross tabulation of surgical repair of cleft and level of satisfaction of appearance

Click here to view

In [Table 3], the occlusal features of the participants were highlighted. Twenty-four (75.0%) patients presented with at least one incisor with a positive overbite, 21 (65.63%) with a positive overjet, 16 (50.0%) with anterior tooth rotations, 13 (40.63%) had crossbite and edge-to-edge bite, and 8 (25.0%) had anterior tooth displacements. There was no recorded crossbite among patients with repaired cleft palate only. More than half of the participants 17 (53.8%) with anterior crossbite had repaired cleft lip and palate.

Table 3: Cross tabulation of type of repair and occlusal characteristics of anterior teeth of patients

Click here to view

Discussion

Cleft lip and palate patients suffer from various orthodontic anomalies which include a retrusive maxilla, problems in skeletal transverse and vertical planes, anomalies in dental development as well as varying degrees of malocclusion.

Several occlusal anomalies may be seen in patients with repaired cleft lip and/or palate; in some studies, almost all the patients exhibited at least one occlusal anomaly.^{[16],[17],[18]} In our study, we observed reduced and/or reversed overbite, reduced and/or reversed overjet, displacement, rotation, and crossbite of the anterior teeth of the participants.

Although many of our participants indicated that they would want treatment of these malocclusions, they did not know how or where to do so. This seems to be a common problem in Nigeria due to our “pay out-of-pocket” health-care system as well as ignorance of the possibility of orthodontic correction for these anomalies. Similar concerns of inadequate funds and financial difficulties in accessing other nonsurgical care for cleft patients have been expressed in other parts of Nigeria.^[14] A high default rate after cleft lip repair has also been recorded in Nigeria, which could be not only a consequence of financial difficulties but also lack of awareness of the patient who primarily may be more concerned about facial esthetics.^[15] The lack of attendance by patients at recall visits coupled with a lack of orthodontists in some parts of the country has made the orthodontic correction of these anomalies improbable. These factors contribute greatly to the lack of access to orthodontic care for these patients.

Residual occlusal anomalies that occur after surgical repair of clefts have a negative psychosocial effect on many individuals which was attested to by our participants. This further makes it imperative to draw the attention of the relevant authorities to the gap in the management of cleft lip and palate patients in our society which should be provided by the orthodontist. Orthodontic intervention in the mixed dentition is advocated by various authors.^[19] These procedures include maxillary expansion to correct the reduced transverse dimension, maxillary protraction to reduce the retrusion and proper alignment of the incisors in addition to alveolar bone grafting.^[20] These procedures have a positive effect on the self-esteem of the patient and prevent psychological damage that is associated with cleft lip and palate.

Space closure after successful bone grafting in these patients may be needful and may be managed by the prosthodontist, but orthodontic treatment has been proven to be superior and more desirable than restorative treatment over the years. There are numerous reports of successful orthodontic outcomes not only in the mixed dentition but also in the permanent dentitions of patients with repaired clefts.^[21] Some residual problems may be present which require the services of the restorative dentist, periodontologist, oral and maxillofacial surgeon among others.

Conclusions

Based on the findings of our study that almost all the patients with repaired clefts of varying degrees had malocclusions, we are recommending that the orthodontist be in cooperated into every cleft team in our environment in order to enable the cleft patient to have an overall better quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of ineterest.

References

1.	Cooper HK. Integration of services in the treatment of cleft lip and cleft palate. J Am Dent Assoc 1953;47:27-32.
2.	Harvold E. Cleft lip and palate. Am J Orthod Dentofacial Orthop 1954;40:493-506.
3.	Robertson NR, Hilton R. The changes produced by pre-surgical oral orthopaedics. Br J Plast Surg 1971;24:57-68.
4.	Brauer RO, Cronin TD. Maxillary orthopedics and anterior palate repair with bone grafting. Cleft Palate J 1964;16:31-42.
5.	Rosenstein SW, Dado DV. Cleft lip repair: Trends and techniques. Semin Plast Surg 2005;19:302-12.
6.	de Ladeira PR, Alonso N. Protocols in cleft lip and palate treatment: Systematic review. Plast Surg Int 2012;2012:562892.
7.	Shaikh D, Mercer NS, Sohan K, Kyle P, Soothill P. Prenatal diagnosis of cleft lip and palate. Br J Plast Surg 2001;54:288-9.
8.	Shetye PR. Presurgical infant orthopedics. J Craniofac Surg 2012;23:210-1.
9.	Kirschner RE, LaRossa D. Cleft lip and palate. Otolaryngol Clin North Am 2000;33:1191-215, v-vi.
10.	Levy-Bercowski D, DeLeon Jr. E, Stockstill JW, Yu JC. Orthognathic cleft-surgical/orthodontic treatment. Semin Orthod 2011;17:197-206.
11.	Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 1972;30:87-92.
12.	Aikins EA, Akinbami BO. Perceptions, expectations, and reactions of caregivers to cleft lip and palate repair in a tertiary hospital. Odontostomatol Trop 2016;39:32-8.
13.	Kuijpers-Jagtman AM. The orthodontist, an essential partner in CLP treatment. B-ENT 2006;2 Suppl 4:57-62.
14.	Efunkoya AA, Omeje KU, Amole IO, Osunde OD, Akpasa IO. A review of cleft lip and palate management: Experience of a Nigerian Teaching Hospital. Afr J Paediatr Surg 2015;12:257-60. [PUBMED] [Full text]
15.	Onah II, Opara KO, Olaitan PB, Ogbonnaya IS. Cleft lip and palate repair: The experience from two West African sub-regional centres. J Plast Reconstr Aesthet Surg 2008;61:879-82.
16.	Freitas JA, Garib DG, Oliveira M, Lauris Rde C, Almeida AL, Neves LT, et al. Rehabilitative treatment of cleft lip and palate: Experience of the Hospital for Rehabilitation of Craniofacial Anomalies-USP (HRAC-USP)--part 2: Pediatric dentistry and orthodontics. J Appl Oral Sci 2012;20:268-81.
17.	Akcam MO, Evirgen S, Uslu O, Memikoğlu UT. Dental anomalies in individuals with cleft lip and/or palate. Eur J Orthod 2010;32:207-13.
18.	Menezes R, Vieira AR. Dental anomalies as part of the cleft spectrum. Cleft Palate Craniofac J 2008;45:414-9.
19.	Shetye PR. Orthodontic management of patients with cleft lip and palate. APOS Trends Orthod 2016;6:281-6. [Full text]
20.	Baek SH, Kim KW, Choi JY. New treatment modality for maxillary hypoplasia in cleft patients: protraction face mask with miniplate anchorage. Angle Orthod 2012;80:783-91.
21.	Rocha R, Ritter DE, Locks A, de Paula LK, Santana RM. Ideal treatment protocol for cleft lip and palate patient from mixed to permanent dentition. Am J Orthod Dentofacial Orthop 2012;141:S140-8.