# Incidental Findings in Patients with Cleft Lip and Palate: A Case-Control Study
###### Abstract
The guidelines of the European Academy of Dento-MaxilloFacial Radiology (EADMFR) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) outline that every clinician has the moral responsibility to assess the entire volume of radiographic findings, even beyond the diagnostic purpose for which the image was initially ordered. Thus, if a clinician lacks expertise in CBCT interpretation, an appropriate referral is required to an oral and maxillofacial radiologist [12; 13]. As the access to and the quality of 3D imaging techniques have been rapidly expanded in the past three decades, reports of IFs are increasing [14; 15]. Research has shown that IFs are identified in 6% to 43% of orthodontic patients randomly selected in various clinical sites when conventional 2D radiographs are evaluated [8; 16; 17; 18]. It is, therefore, reasonable that this percentage may be higher when 3D images are analyzed, given the greater volume of data presented in a large FOV CBCT scan. Published research articles have demonstrated that the frequency of IFs observed in CBCT scans ranges from 25% to 94% [15; 19; 20; 21; 22; 23; 24]. In CL/P cases, OPT, LC radiographs, and CBCT scans are usually obtained in the early stages of treatment to evaluate the implications of soft and hard tissues and the extent of the alveolar bone defect. Therefore, any IF depicted in these imaging tests can immensely contribute to appropriate planning for alveolar bone grafting procedures, orthognathic surgery, and comprehensive orthodontic treatment [25]. According to a recent systematic review and meta-analysis [26], individuals with orofacial clefts are more likely to present a variety of dental abnormalities in the maxilla and mandible compared to their unaffected peers. Dental abnormalities appear in most types of clefts, in both cleft and non-cleft sides, and are uniformly distributed in both genders [26]. Tooth agenesis is the most frequently observed dental anomaly among orofacial cleft patients, followed by supernumerary teeth, developmental enamel defects, and microdontia/peg-shaped anterior teeth [26; 27]. The rate of congentially missing teeth was reported at 67.6% to 77% of young patients with CL/P [28; 29]. It is also known that the frequency of patients with missing teeth increases with the severity of the cleft [30]. The incredibly high prevalence of congentially missing teeth in patients with CL/P suggests a possible correlation between these two phenomena. Subsequent research has proven that the occurrence of clefts and hypodontia seems to be controlled by MSX1 genes [31]. Following the dentition, paranasal sinuses are the second most common anatomical area where IFs are found. In contrast, IFs in the nasal cavity, orbit, skull, and cervical spine are reported to have lower rates [14]. Anomalies in middle and inner ear cavities were reported at 29.9% [14]. Young patients with CL/P are prone to middle ear disease due to dysfunction of the Eustachian tube and soft palate muscle [32; 33; 34; 35]. These patients present a very high incidence of otitis media with effusion (OME) and multiple tympanostomy tube placements, especially during childhood and adolescence [34; 35]. Nevertheless, the long-term ontological prognosis is not necessarily ominous since most patients' tympan membranes are in good condition, and hearing is restored to normal levels after 10 years of age [35]. To our knowledge, no published study has addressed the prevalence of IFs in several anatomical locations of patients with non-syndromic CL/P compared with healthy controls until today. Evidence suggests that individuals with a history of CL/P exhibit a high prevalence of IFs, with the estimated rate approaching 95.1% [25] to 95.5% [14]. Non-cleft populations have also undergone investigation to assess the occurrence of IFs. The overall rate of IFs in a young non-cleft population has been reported at 24.6% [15]. However, the results from several studies have not been conclusive [15; 16; 36; 37].