Dentition Precox (Natal tooth) in Cleft lip and palate Neonate – A Rare Case Report

The present case report shows occurrence of “Dentition Precox” or “Natal Tooth” in a 22-days-old Indian baby boy having cleft lip and palate defect, whose parents reported with panic. Although development of congenital malformations like cleft lip/palate in common in India due to increased frequency of consanguineous marriages, occurrence of natal tooth/neonatal tooth in these deformed neonates is an uncommon finding. Knowledge about occurrence of these pre-deciduous teeth is highly essential not only for oral and maxillofacial surgeon or plastic surgeon but also for all specialties to provide appropriate management.

Keywords: Cleft lip/palate, Infant, Natal tooth, Presurgical Naso-alveolar molding

A major milestone expected from parents during baby’s first year life is eruption of milk teeth. Sometimes neonates are born with tooth like structures before the eruption of normal deciduous teeth which is an unusual occurrence. These teeth are referred as ‘Dentition Precox,’ ‘Fetal teeth,’ ‘Natal/Neonatal teeth,’ ‘Congenital teeth’ and ‘Predeciduous teeth.’ According to Massler and Savara “Natal tooth” can be defined as teeth present at birth and “Neonatal teeth” are those that erupt within the first month of life [1]. The exact prevalence of these teeth in normal infants is not known and studies reported incidence ranging from 1:2,000 to 1:3,500 live births [1,2].

Cleft lip and palate are the most commonly seen congenital malformation in India due to increased frequency of consanguineous marriages among different ethnic groups of population [2]. This congenital deformity brings many problems including esthetic, psychological, financial, functional and emotional aspect not only for the infant but also for whole family throughout the life of affected one. In these individuals, treatment starts from the first day of neonate life and extends till adulthood. Various factors should be considered during the management of these patients which include presence of anomalies, health of the neonate, caring of the soft tissue defects and mainly feeding aspects. Literature search reveals scarcity of publications on the occurrence of congenital variations like occurrence of natal tooth in these cleft lip and palate neonates [3,4]. Therefore, the purpose of this manuscript is to elucidate the occurrence of natal tooth in a 22-days-old neonate born to a couple of Indian origin, as its presence brings plethora of reactions in parents and also affects various management aspects prior to surgery.

Indian couples brought their baby boy who is 22-days-old and born with cleft lip and palate defect to the private hospital complaining of presence of tooth like structure in the upper jaw of mouth. Baby appeared absolutely normal on physical examination with moderate built and nourishment. Family history revealed no history of occurrence of such defect in their family and parents’ personal history elicited history of consanguineous marriages between mother and father. Baby was born through normal delivery following complete nine months of development. Examination of the cleft defect showed presence of unilateral cleft lip including hard palate. The right nostril was deformed due to the cleft defect. On further observation, a small, rudimentary and slight whitish in color tooth structure was observed attached to the gum pad in the region of 61 (maxillary left primary central incisor position), at the edge of cleft defect (premaxillary region) (Figure 1).

Figure 1: Presence of Dentition Precox (Natal tooth) in the maxillary left primary central incisor region attached to the gum pad of premaxilla.

No other findings were observed in the oral cavity apart from this. The tooth exhibited slight mobility on palpation. Parents gave a history of presence of this tooth at the time of birth along with the cleft defect. They worried while feeding the baby thinking this might get swallowed by the baby. Finally, this was diagnosed as a case of ‘natal tooth’ and extraction was carried out under topical local anesthetic application following aseptic precautions. After the extraction, parents were asked to wait for some time ensuring complete stoppage of bleeding. Following the extraction, examination of the natal tooth showed absence of root structure with presence of only crown structure (Figure 2).

Figure 2: Extracted natal tooth showing no root structure

The presence of prematurely and precociously erupted teeth bring plethora of consequences with combined misconceptions among people which in turn have a great impact on both functional as well as psychological aspects of child’s life and emotions of the whole family. It is evident from a single Indian study [5], that shows a higher prevalence of natal and neonatal teeth in the cleft lip and palate neonates. However, there is no proper research data exclusively documenting from a cleft center regarding its prevalence.

The presence of natal/neonatal tooth in cleft lip and palate patients is associated with a greater significance compared to normal individuals [4-6]. The management of these teeth is entirely different from normal infants. As cleft lip and plate infants require feeding plates or soft tissue molding appliances immediately after birth, the treatment of natal or neonatal teeth requires a precautionary step [7-10]. Sometimes dental radiograph is essential in identifying the premature eruption of deciduous tooth. Some researcher say it is wise to preserve and maintain the tooth in healthy condition using all clinical treatments [5]. However, majority of reports suggested for extraction of all natal/neonatal teeth to be a safer side [6-10]. Pertaining to cleft lip and palate infants, the extraction of these should be compulsory. As cleft lip/palate infants require feeding plates, presurgical soft tissue molding and pre-orthopedic surgical procedures prior to the definitive primary and secondary surgeries, presence of these teeth in cleft lip/palate patients interferes with impression taking, fabrication and application of these appliances inside the oral cavity [6-10]. Therefore, in cleft centers where presurgical naso-alveolar molding is carried out for all cleft lip and palate infants prior to the surgery, compulsory extraction of these pre-deciduous teeth is carried out to facilitate easy fabrication and application of presurgical naso-alveolar molding approach [9,10] .

During extraction of natal/neonatal teeth, some clinical protocols need to be followed. The extraction is not indicated in neonates who are less than 10 days older. Because at this period, intestinal bacterial flora is less and ineffective in Vitamin K production which is essential in synthesis of prothrombin. Therefore, if extraction is done at this period, risk of hemorrhage due to hypoprothrombinemia occurs keeping the baby at risk. If at all extraction is required in such circumstances like increased mobility in natal/neonatal tooth or due to risk of aspiration of the tooth or if severe ulceration seen which occurs due to sharp edge of the tooth (in case of Riga-Fede disease), reports [2-10] have suggested to administer Vitamin K injection. Therefore, laboratory test involving assessment of prothrombin and Vitamin K level is mandatory in these patients prior to extraction. Following extraction of these teeth, healing at the extraction region takes place after a week, then presurgical nasoalveolar molding can be started [9,10]. Suppose if healing period extends for longer time, then modifications in presurgical nasoalveolar molding appliance/feeding plate has to be done. Some patients may require only horizontal lip bands till soft tissue healing. However, it is also recommended to modify the borders of the intra oral plate till the soft tissue healing occurs completely.

There is lack of overall awareness and poor perception towards treatment of these deformed patients in India [9]. Therefore, an awareness and knowledge about the management of natal and neonatal teeth in cleft lip and palate neonates is highly essential in order to counsel, educate, and motivate parents to go for comprehensive treatment approach including presurgical naso-alveolar molding prior to opt for surgical therapy [10].

Occurrence of ‘Dentition Precox’ or ‘Natal and Neonatal teeth’ in cleft lip/palate neonates is an uncommon finding. Management of these teeth in neonates affected with cleft lip/palate infants is more different and important compared to infants without cleft defect. Knowledge about their occurrence is highly essential among all clinicians for providing overall utmost care to the tiny, tender neonates.