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Guagnano et al. Plast Aesthet Res 2020;7:37 I http://dx.doi.org/10.20517/2347-9264.2020.21 Page 3 of 10

The aims of the present study were to assess the association between timing of hard palate surgery
and dental anomalies in a sample of Italian cleft children and to investigate the relationship of dental
abnormalities with gender, ethnicity and cleft type.

METHODS
All patients included in the present study were affected by non-syndromic facial cleft and were
consecutively selected among outpatients referred for dental examination to the Section of Paediatric
Dentistry, C.I.R. Dental School, University of Turin from April to July 2019. Patients were excluded if they
were affected by lip or soft palate cleft, suffered from any disease associated with increased risk for dental
anomalies or underwent previous extractions or fixed orthodontic treatment so that all dental surfaces
could be accessible to the clinical examination and tooth agenesis as well as structural dental anomalies
could not be considered iatrogenic.

The protocol of the present study was approved by the local Ethics Committee (No. 0038526), and written,
informed consent was obtained from each patient or their parent or guardian. The investigation was
performed according to the ethical principles of the Helsinki declaration.

Enrolled patients were classified into two groups depending on the timing the different surgical protocols
were carried out. All patients who received one-stage periosteal plastic of the hard palate together with
lip and soft palate repair were classified into the early periosteal palate plastic surgery group (EPP). This
technique includes the treatment of maxillary defects and the closure of the lip at the age of 2-6 months.
Cleft lip was repaired using a modified Tennison-Randall technique or a modified Mulliken technique.
Cleft palate was repaired using Bardach technique or Von Langenbeck technique.

The patients included in the delayed palate repair surgery group (DPR) underwent first an infant orthopaedic
treatment by the use of a Hotz neonatal plate followed at the age of 3-6 months by a lip repair procedure
according to modified Millard or Noordhoff techniques. Soft palate repair was done at 8-10 months
of age according to Widmaier-Perko technique, combined with V-Y repositioning of the soft palate without
touching either the palatal artery or the palatal periosteum. Hard palate repair was performed at 4 years
of age according to Schweckendiek technique with a mucoperiosteal flap. This is the current surgical
treatment protocol to which cleft palate children treated at the Plastic Surgery Division of the Regina
Margherita Children Hospital of Turin are submitted.

Data on age, gender, ethnicity, concomitant systemic pathologies, type and side of cleft and type and time
of surgical corrections were collected from questionnaire and medical records. A specialist in paediatric
dentistry evaluated the dental conditions of cleft children. Diagnosis of carious lesions was based on the
[16]
criteria established by the World Health Organisation . Each patient was given a score resulting from
the sum of the decayed, missing and filled teeth either in primary (date index) or in permanent dentition
(DMFT index). Patients with mixed dentition had two separate scores.

Disturbances of enamel mineralisation were examined on permanent teeth and recorded using the Aine
rating scale where Grade I defines qualitative defects (opacities and discolorations), while Grades II, III and
[17]
IV represent quantitative defects (hypoplasia) of increasing severity .
Intraoral examination and panoramic radiographs were used to determine the following dental anomalies:
number of impacted, missing, supernumerary or microdontic teeth, abnormalities in crown shape and
ectopic eruption of permanent molars. Dental anomalies (fusion of deciduous teeth) were assessed only by
intraoral examination for patients younger than 6 years of age.