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Page 8 of 10 Guagnano et al. Plast Aesthet Res 2020;7:37 I http://dx.doi.org/10.20517/2347-9264.2020.21

a lower percentage compared to that reported in the literature, ranging from 18% to 37% [19-24] . Conversely,
[21]
only a minority of patients (6%) showed primary fused teeth, as previously observed by Suzuki et al. .
Notably, fusion of deciduous teeth in the present study was always followed by the agenesis of the
permanent teeth.

Tooth impaction was observed in 8.4% of the patients and ectopic eruption of molars in 7.2% of the cases.
These percentages were lower compared to data reported in the literature, which varied from 10% to 50% [19-25]
[26]
and from 15% to 28% , respectively.

[27]
Worth et al. reported that the dental caries prevalence in cleft lip palate patients is higher than that
observed in healthy children, in both deciduous and permanent dentition, with a pooled mean difference
in dmft of 0.63 (95%CI: 0.47-0.79) and in DMFT of 0.28 (95%CI: 0.22-0.34). In the present cleft population,
caries experience was two-fold higher in primary than in permanent teeth. Dental anomalies in the
deciduous dentition may predispose the affected teeth to greater accumulation of bacterial plaque and
[28]
consequently to dental caries . Thus, counselling and follow-up are important to maintain the integrity of
teeth in order to maintain the supportive bone structures that may be defective at the cleft area.

[29]
Finally, in line with previous studies , enamel defects, varying from opacity and discoloration to mild
and evident structural changes, were more frequently observed in upper left lateral and central permanent
[14]
incisors. In agreement with Korolenkova et al. , we observed a statistically significant association between
early periosteal plastic surgery of the palate and higher number of carious lesions in deciduous teeth
or severe degree of enamel defects in permanent dentition and a higher prevalence of permanent tooth
agenesis. A possible explanation could be that an early surgery on hard tissues, when primary teeth are
erupting and permanent teeth (particularly the incisors) are developing, can interfere with blood supply
of dental buds, resulting in more enamel defects up to agenesis. Indeed, the lower percentage of damage to
[29]
dental enamel reported in our study (49% vs. 87.9% ) could be related to the fact that most of the patients
underwent late surgical repair of the hard palate, with less impact on dental development, while the most
severe consequences were observed in patients treated early in life.

The limitation of the present study is the heterogeneity of enrolled patients in terms of type of cleft,
ethnicity and surgical procedures for cleft repair. In addition, the study sample was a convenience sample,
but it provided significant results about the association between surgical timings and dental anomalies in
cleft lip palate patients, suggesting that prevalence of dental abnormalities may also depend on treatment
protocol.

Further multi-centre studies with larger numbers of cleft children should be performed to investigate
timing, type of surgical cleft repairs, clinical and patient-related outcomes in order to identify the most
appropriate surgical approach to optimise both speech outcomes and maxillary bone development while at
the same time limiting the detrimental impact on both primary and permanent dentition. While early hard
[30]
palate repair improves speech production, delayed repair allows for better maxillary growth . Intensive
speech therapy directed at the correction of articulation errors should be implemented as soon as possible
to improve overall communication.

Interdisciplinary management and proper follow-up of these patients are crucial and paediatric dentists
must be conscious about the dental needs of these subjects in order to improve their quality of life.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study: Guagnano R, Defabianis P
Performed data acquisition and provided administrative, technical, and material support: Guagnano R