Ban.doc J Bagh College Dentistry Vol. 27(2), June 2015 Congenitally missing Pedodontics, Orthodontics and Preventive Dentistry148 Congenitally missing and supernumerary teeth among a group of 3-12 years old children with cleft lip and/ or palate in Iraq Zainab J. Ja'far, B.D.S., M.Sc. (1) Ban Ali Salih, B.D.S., M.Sc. (2) ABSTRACT Background: There are many congenital anomalies associated with cleft lip and/or palate. This research is to study the prevalence of congenitally missing teeth and supernumerary teeth in this population group. Materials and Method: One hundred eight cleft lip and/or palate Iraqi patients had participated in this study (57 male, 51 female), 3-12 years of age. 26 of them had orthopantomogram were within (6-12) years of age were inspected for congenitally missing teeth and supernumerary teeth. Patients whom age range 3-5 years were checked for the congenitally missing teeth by clinical examination with strongly insisting the teeth were not missed due to caries or trauma. Results: There were 19(73.076%) patients with 41 congenitally missing teeth for the 26 patients within 6-12 years age group who were with orthopantomogram, while there were 20(37.037%) patients with 32 congenitally missing teeth for the 54 patients within 3-5 years of age who were not indicated for orthopantomogram. There were (22) patient with (27) supernumerary teeth. Conclusion: The most frequently congenitally missing tooth was the permanent upper lateral incisor, on the other hand the tooth most frequently noted as extra tooth was the primary lateral incisor. Majority of them were with cleft lip and palate. Key words: Cleft lip and / or palate, congenitally missing teeth, supernumerary teeth. (J Bagh Coll Dentistry 2015; 27(2):148-153). INTRODUCTION Numerical abnormalities are not uncommon in the dentition of the normal population, it is reasonable to consider cleft and normal populations have the backgrounds with similar numerical variations (1,2). Congenitally missing teeth( C.M.T.), supernumerary teeth (S.N.T.) have been shown to occur more frequently in cleft lip and/or palate children than normal children(3,4).Millet and Wellbury said that on the cleft side, the lateral incisor is either absent, of abnormal size and/or shape, hypoplastic or as two conical teeth on either side of the cleft (5). Kraus et al, 1966 found 8 cases of S.N.T. in 25 CLP group (6). The site of S.N.T. was between the central incisor and cuspid in all patients (7). MATERIALS AND METHODS One hundred eight CL (P) Iraqi patients had participated in this study (57 male, 51 female), 3- 12 years of age. Approval was achieved from Ministry of Higher Education and Scientific Research, and Ministry of Health for examining the cleft patients. The presence of C.M.T. or S.N.T. had been assessed on O.P.G. if present (26) who were within (6-12) years of age were inspected for C.M.T. and S.N.T. (1)Lecturer. Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad (2)Professor, Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad Patients whom age range 3-5 years were checked for the C.M.T. by clinical examination with strongly insisting the teeth were not missed due to caries or trauma. Chi-square was used to assess two categorical variables (frequency of data), such as the presence of C.M.T. according to the type of cleft. RESULTS Congenitally missing teeth Patients with O.P.G. who were within (6-12) years of age were inspected for C.M.T. and the results were demonstrated in table (1). The highest percentage (30.77%) had one or two C.M.T. It is evident from the table that there were 19 patients with 41 C.M.T. in the sample that the O.P.G. was available. Patients without O.P.G. who were within (3-5) years of age were inspected for C.M.T. clinically and the results were demonstrated in table (2). The highest percentage (50%) had one C.M.T. It is evident from the table that there were 20 patients with 32 C.M.T. in the sample that the O.P.G. was not indicated. Table (3) demonstrates the presence or absence of hypodontia in different cleft types in the sample with O.P.G, the highest value for the presence of hypodontia is for the CLP with statistically non significant difference (P=0.11). It reveals that 19 from the 26 patients examined are with hypodontia. Table (4) demonstrates the presence or absence of hypodontia in different cleft types in J Bagh College Dentistry Vol. 27(2), June 2015 Congenitally missing Pedodontics, Orthodontics and Preventive Dentistry149 the sample without O.P.G, the highest value for the presence of hypodontia is for the CLP with statistically highly significant difference (P=0.0009). It reveals that 20 from the 54 patients examined are with hypodontia. Table (5) demonstrates the different number of C.M.T. in different cleft types in the sample with O.P.G. The highest accounts are for the CLP patients with one or two C.M.T. with statistically non significant difference. Table (6) demonstrates the different number of C.M.T. in different cleft types in the sample without O.P.G. The highest accounts are for the CLP patients with one then two C.M.T. with statistically non significant difference. Table (7) illustrates the frequency and percentage of different types of C.M.T. in the sample with O.P.G. The highest percentage is for the permanent upper lateral incisor with statistically highly significant difference (P=0.001). Table (8) illustrates the frequency and percentage of different types of C.M.T. in the sample without O.P.G. The highest percentage is for the primary upper lateral incisor with statistically highly significant difference (P=0.0001). Supernumerary teeth In the selected sample which comprise (108) patients, there were (27) supernumerary teeth found in (22) patient. Table (9) demonstrates the distribution of patients with no, one, or two S.N.T. Table (10) demonstrates the frequency and percentage of patients in every type of S.N.T. in the selected sample. The highest percentage was the primary upper lateral incisor (9.2%). Table (11) demonstrates the frequency and percentage of teeth in every type of S.N.T. in the selected sample. The highest percentage was (40.74%) for the primary upper lateral incisor. Table (12) demonstrates the number of S.N.T. according to patient with or without O.P.G.. There was a statistically non significant difference (P=0.97). Table (13) demonstrates the number of S.N.T. according to type of cleft. There was a statistically significant difference (P=0.03). Table 1: Number and percentage of patients with O.P.G. had different number of C.M.T. Patients with O.P.G. C.M.T. (no.) % No. 26.92 7 0 30.77 8 1 30.77 8 2 3.85 1 4 3.85 1 5 3.85 1 8 100 26 Total Table 2: Number and percentage of patients without O.P.G. had different number of C.M.T. Patients without O.P.G. C.M.T. (no.) % No. 50 10 1 45 9 2 4 1 4 100 20 Total Table 3: Presence or absence of hypodontia in different cleft types of the sample with O.P.G. Hypodontia Diagnosis CL CP CLP Total No. % No. % No. % No. % Present 1 3.9 2 7.7 16 61.5 19 73.1 Not present 2 7.7 3 11.6 2 7.7 7 27 Total 3 11.6 5 19.3 18 69.2 26 100 X²=7.4 df=2 P=0.11*(NS) Non significant. J Bagh College Dentistry Vol. 27(2), June 2015 Congenitally missing Pedodontics, Orthodontics and Preventive Dentistry150 Table 4: Presence or absence of hypodontia in different cleft types of the sample without O.P.G. Hypodontia Diagnosis CL CP CLP Total No. % No. % No. % No. % Present 2 3.7 0 0 18 33.3 20 37 Not present 5 9.3 15 27.8 14 25.9 34 23 Total 7 13 15 27.8 32 59.2 54 100 X²=14.10 df=2 P=0.0009*(HS) *Highly significant. Table 5: Different number of C.M.T. in different cleft types in the sample with O.P.G. C.M.T. (No.) Diagnosis CL CP CLP Total 1 1 0 7 8 2 0 1 7 8 4 0 1 0 1 5 0 0 1 1 8 0 0 1 1 Total 1 2 16 19 X²=13.9 df=8 P=0.17(NS)* Non Significant Table 6: Different number of C.M.T. in different cleft types in the sample without O.P.G. C.M.T. (No.) Diagnosis CL CP CLP Total 1 1 0 9 10 2 1 0 8 9 4 0 0 1 1 Total 2 0 18 20 X²=0.123 df=4 P=0.055(NS)* Non Significant Table 7: Distribution of different types of C.M.T in the sample with O.P.G. Frequency Percentage Permanent upper lateral incisor 25 60.98 Permanentlower second premolar 6 14.63 Permanent upper second premolar 6 14.63 Permanent upper central incisor 3 7.32 Permanent lower central incisor 1 2.44 Total 41 100 X²=66.5 df=4 P=0.001(HS)*** Highly significant Table 8: Distribution of different types of C.M.T in the sample without O.P.G. Frequency Percentage Primary upper lateral incisor 25 78.125 Primary upper central incisor 5 15.625 Primary lower central incisor 2 6.25 Total 32 100 X²=76.8 df=2 P=0.0001(HS) ***Highly significant Table 9: Distribution of patients with no, one, or two S.N.T. S.N.T. No. No. of patients % 0 86 79.6 1 17 15.7 2 5 4.6 Total 108 100 J Bagh College Dentistry Vol. 27(2), June 2015 Congenitally missing Pedodontics, Orthodontics and Preventive Dentistry151 Table 10: Type of S.N.T. in the selected sample. S.N.T-Type No. of patients % No 86 79.8 Permanent mesodens 6 5.5 Permanent lateral incisor 2 1.8 Primary mesodens 2 1.8 Primary lateral incisor 10 9.2 Primary central incisor 1 0.9 Primary lower central 1 0.9 Total 108 100 Table 11: Number and percentage of types S.N.T. % No. of teeth S.N.T. type 11.11 3 Primary mesodens 29.63 8 Permanent mesodens 7.40 2 Permanent upper lateral 40.74 11 Primary upper lateral 3.70 1 Primary upper central 7.40 2 Primary lower centrals 100 27 Total Table 12: Number of S.N.T. according to patient with or without O.P.G. S.N.T. No. O.P.G Yes No Total No.* % No.* % No.* % 0 21 19.40 65 60.20 86 79.60 1 4 3.70 13 12.00 17 15.70 2 1 0.90 4 3.70 5 4.60 Total 26 24.10 82 75.90 108 100 X²= 0.05 df= 2 p=0.97(N.S)** * Number of patients, **Non significant Table 13: Number of S.N.T. according to type of cleft. S.N.T. No. Diagnosis CL CP CLP Total No.* % No.* % No.* % No.* % 0 7 6.50 24 22.20 55 50.90 86 79.60 1 6 5.60 2 1.90 9 8.30 17 15.70 2 1 0.90 1 0.90 3 2.80 5 4.60 Total 14 13.00 27 25.00 67 62.00 108 100 X²= 10.08 df= 4 p=0.03(S)** *Number of patients, **Significant DISCUSSION Congenitally missing teeth The presence of C.M.T. had been assessed on O.P.G. if present (n=26), this proportion was low because the children under 6 years of age were not be permitted to take an O.P.G., and this age group constituted a high percentage from the selected sample (50%), also some centers from which the sample collected had no O.P.G. machine, so only this number of patients were able to take this type of x-ray and their age ranges 6-12 years. There were 19(73.076%) patients with 41 C.M.T. for the 26 patients within 6-12 years age group who were with O.P.G., while there were 20(37.037%) patients with 32 C.M.T. for the 54 patients within 3-5 years of age who were not indicated for O.P.G. These are in accordance with Ranta and Rintala (8)Shapira et al (9) for the first; and with Hellquist et al (10); Ranta et al (11); and Abd.Rahman et al (12) for the second; While these values are higher than that of Dahllöf et al (13); Al- Janabi (14); and Kirzioğlu et al. (15). This difference may be due to different racial and ethnic origin, genetic factors, method of examination, sample size and homogenicity, age groups, in addition to surgical procedures. According to the type of cleft, the majority of the 6-12 years old patients with C.M.T. are under the diagnostic criteria of CLP(61.5%), followed by patients with CP(7.7%), and the least account J Bagh College Dentistry Vol. 27(2), June 2015 Congenitally missing Pedodontics, Orthodontics and Preventive Dentistry152 is for the CL (9.3%) with statistically non significant difference (P=0.11). This result agree with Fishman, 1970(16), while for patients within 3-5 years of age who were without O.P.G. the majority also (33.3%) were CLP patients, followed by CL (3.7%) and no C.M.T. were observed in isolated CP. These results agree with Kirzioğlu et al (15). The most frequently congenitally missing teeth were the upper lateral incisor (25 primary teeth, 25 permanent teeth), then the upper and lower second premolar (6) and the primary upper central incisor (5)come next, then the permanent upper central incisor (3 teeth), primary lower central incisor (2 teeth), and the least is for the permanent lower central incisor(1 tooth). These outcomes are similar to that of Jones et al. (17,18). While these results disagreed with Al-Wahadni et al. (19). Numerical abnormalities are not uncommon in the dentition of the normal population, where maxillary and mandibular second premolars are the most commonly missing permanent teeth (2). It is reasonable to consider cleft and normal populations have the backgrounds with similar numerical variations. Thus, these findings suggest that the maxillary lateral incisors are missing more often than they are in normal populations. Millet and Wellbury said that on the cleft side, the lateral incisor is either absent, of abnormal size and/or shape, hypoplastic or as two conical teeth on either side of the cleft (5). Many theories have been advanced attempting to explain why so many teeth are missing in children with clefts. These theories include multiple genetic and environmental factors, mesenchyme deficiency, and direct effect of cleft on the primordial tissue related to the development of the lateral incisor (20). Nutritional factors due to an initial lack of bone tissue around the tooth germs or a congenitally inadequate blood supply to the area in question may, instead, be considered to affect the dental development in the cleft area (21). Viral and bacterial infection may well be a more important etiologic factor than heredity, but only more detailed research can confirm or deny this possibility (7). Some consider the same etiologic factor or factors seem to be responsible both for the formation of cleft and for advanced hypodontia in children with CLP which are likely result of a prenatal injury interacting with a poorly buffered genotype (22). Dixon suggested that surgical treatment of the cleft during the period of hard tissue formation of the permanent teeth may affect their development in some cases (23). Hypodontia is believed to be a consequence of physical obstruction or description of dental lamina, space limitation, functional abnormalities of the dental epithelium, and failure of initiation of the underlying mesenchyme (24). Supernumerary teeth (S.N.T.) From the 108 cleft children examined, there are 22(20.3%) children with 27 S.N.T. Five from these 22 patients are with 2 S.N.T., while the remaining 17 are with one S.N.T. for each child. This finding is similar to that of Dahllöf et al (13). At the same time it is lower than that recorded by Ribeiro et al (25), while it is higher than that of Al- Janabi (14). This difference may be due to different racial and ethnic origin, genetic factors, method of examination, sample size and homogenicity, age groups, in addition to surgical procedures. The tooth most frequently noted as extra tooth was the primary lateral incisor (11 teeth), then the primary mesodens (8 teeth), then the permanent mesodens (3 teeth),then permanent upper lateral incisor and primary lower central (2 teeth for each)and the least frequency for the primary upper central incisor (1 tooth). This outcome is in agreement with Fishman (16); Jones et al. (17,18). The frequency of S.N.T. in the primary dentition is more than that in the permanent dentition, which is in accordance with Abd- Rahman (12). By using the O.P.G., from the 26 patients examined, there were 5(4.6%) children with (6) S.N.T. compared to 82 children without O.P.G. in which there are 17(15.7%) with (21) S.N.T. with statistically non significant difference (P=0.97). According to the type of cleft, CLP had the highest number of S.N.T.(12), followed by CL(7), and the least frequency was for the CP(3) with statistically significant difference. These findings agree with that recorded by Fishman (16). But disagree with Berkowitz (26). This result can be explained by the alveolar ridge in isolated CP is not disturbed by the cleft deformity, so it will not affect the tooth germ in its developmental period, as it has been argued that the clefting process splits the tooth germ into two separate teeth (27). Jones et al 1994 and 2004 said that there is a significant increase in the frequency of S.N.T., often with complete unilateral or bilateral clefts. Insisting on the somatic effect, Inoue, 1915 supported the idea that the development of a third incisor is attributed to incomplete fusion of the germ of the second incisor. The length of dental lamina is regarded as a determining factor for the number of teeth in the region. Dental lamina is present before the several parts coalesce to form the maxilla. In instances, in which malformation arise, as in case of cleft palate, a lateral incisor cast into the cleft can be split to form a J Bagh College Dentistry Vol. 27(2), June 2015 Congenitally missing Pedodontics, Orthodontics and Preventive Dentistry153 supernumerary tooth, or be obliterated to be congenitally absent or markedly malformed (27). REFERENCES 1. Silverman NE, Ackerman JL. Oligodontia: a study of its prevalence and variation in 4032 children. J Dent Child 1979; 46: 470-7. 2. Zhu JF, Marcushamer M, King LD, Henry RJ. Supernumerary and congenitally absent teeth.A literature review. J Clin Pediatr Dent 1996; 20:87-95. 3. 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Berkowitz S. State of the art in cleft palate orofacial growth and dentistry. Am J Orthod 1978; 74(5):564- 76. 27. Millhon JA, Stafne EC. Incidence of supernumerary and congenital missing lateral incisor teeth in eighty- one case of harelip and cleft palate. Am J Orthod & O Surg (sec O. Surg) 1941; 27:599-604. :الخالصة وھذا البحث لدراسة انتشار االسنان المفقودة والدیا واالسنان الزائدة والدیا . أو شق الحنك الوالدي \توجد الكثیر من العیوب الخلقیة المصاحبة لشق الشفة و: المقدمة .في ھذا النوع من الناس 12-3تتراوح اعمارھم من ) من االناث 51, من الذكور 57(و شق الحنك الوالدي أ \طفل یعانون من شق الشفة و 108شارك في ھذه الدراسة : األدوات والطریقة بینما . وتم فحص االشعة لتسجیل االسنان المفقودة والدیا والزائدة والدیا, سنة 12-6توفرت لھم األشعة الوجھیة والذین ھم بأعمار ) طفل 26(البعض منھم. سنة أكید ال یمكن أخذ االشعة الوجھیة لھم بسبب تأثیر االشعاع لذلك تم الفحص السریري لتسجیل االسنان المفقودة والدیا والزائدة والدیا مع الت 5-3األطفال من عمر .على أن االسنان المفقودة لم یفقدھا الطفل نتیجة التسوس او الحوادث سنة من العمر ممن توفرت لنا صورھم الشعاعیة بالتصویر 12-6طفل الذین بین 26سن مفقود والدیا من ال 41ى لدیھم من المرض%) 73.076(19ھناك : النتائج سنة من العمر ممن ال تتوفر لنا صورھم الشعاعیة 5-3طفل الذین بین 54سن مفقود والدیا من ال 32من المرضى لدیھم %) 37.037( 20بینام ھناك , الوجھي .سنا) 27(مریضا لدیھم اسنان زائدة والدیا 22وھناك . وجھي وذلك للخوف علیھم من التأثیر اإلشعاعيبالتصویر ال والسن األكثر تھورا كسن زائد والدیا كان القاطع اللبني الثاني في الفك , السن األكثر تھورا كسن مفقود والدیا كان القاطع الثاني الدائمي في الفك األعلى: الخاتمة كثر الحاالت كانت شق الشفة والحنكأ. األعلى