Case 1
CC
An 18-year-old patient with unilateral cleft lip and palate wants to improve his esthetics and function ( Fig. 63.1 ).
HPI
The patient underwent surgery at 3 months of age for cleft lip repair, and later at 18 months, his palate was closed. He underwent speech therapy and presented with no hypernasality, glottal stops, or pharyngeal fricatives.
Examination
Alert and in no distress; anxious about the possible treatment.
Vital signs. Within normal limits.
Nose. Deviated nasal pyramid, deviated septum, asymmetric alas,
Oral cavity. Severe class III malocclusion, severe maxillary teeth misalignment, missing several upper teeth, a small alveolar fistula into the nose. Lip and palate scars. Perinasal deficiency, lower lip procumbent.
Imaging
Severe maxillary deficiency, with teeth #1, #6, #7, #16, #17, and #32 impacted. Right alveolar cleft and missing teeth #10 and #11.
Sella-nasion, A point, 75; SN, B point, 81; ANB (Anterior Nasal Spine), –6.
Assessment
Severe nasal deformity with asymmetry, severe maxillary deficiency,
severe class III malocclusion, and procumbent lower lip.
Treatment
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Presurgical orthodontics mechanics for 6 months before the surgery to align and level and improve 1MPA (Mandibular plane angle)
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Maxillary high Le Fort I advancement via distraction osteogenesis ( Fig. 63.2 )
• Fig. 63.2 Maxillary high Le Fort I advancement via distraction osteogenesis. - •
Transverse maxillary widening
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Alveolar bone grafting from mandibular bone obtained from the osteotomies, adding bone morphogenetic protein–2 and three-dimensional (3D) closure ( eFig. 63.3 )
• eFig. 63.3 A–F, Serial radiographs showing the results of distraction osteogenesis and alveolar bone grafting from mandibular bone obtained from the osteotomies, adding bone morphogenetic protein–2 and three-dimensional closure.
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Mandibular subapical osteotomy, removing teeth #21 and #28 and closing the spaces
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Lower lip mucosa 5-mm resection at the subapical incision to improve lower lip balance with the upper lip ( eFig. 63.4 )
• eFig. 63.4 A–C, Outcome of mandibular subapical osteotomy, removing teeth #21 and #28 and closing the spaces. Lower lip mucosa 5-mm resection at the subapical incision to improve lower lip balance with the upper lip.
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Extraction of teeth #6, #7, #17, and #32
After the orthognathic surgery was finalized, the anesthesia tube was changed to the oral route, and rhinoplasty was performed. It was an open rhinoplasty with lateral cartilage resection and repositioning, Weir procedure, and lateral nasal osteotomies and repositioning. A splint was placed over the nose at the end of the surgery. The distractors were activated 1 week after surgery, 1 mm a day for 10 consecutive days. Appliances were removed 6 months after surgery after the maxilla was very stable. This was done in the clinic under intravenous sedation.
Orthodontics resumed 3 weeks after surgery, and active treatment was completed in 18 months. Retention was then maintained ( eFig. 63.5 ).
Case 2
CC
A 17-year-old patient came to the clinic with poor dental occlusion after 3 years of orthodontics. Her main concerns were her upper dental midline, which was 3.5 mm deviated to the left, and her lower left canine, which was completely outside the mandibular arch. Her bite was off, and she had facial muscle pain.
HPI
She had a congenitally missing #10 tooth. Her orthodontist closed the dental space with braces, and after treatment, her right lower canine does not fit into the mandibular arch. She wants to have the dental midline corrected and to have straight lower teeth.
Examination
Alert and in no distress; anxious about the possible treatment.
Vital signs. Within normal limits.
Oral. The maxillary dental midline was 3.5 mm deviated to the left, and she was missing the left maxillary lateral incisor. The orthodontist closed the dental space by applying mechanics. Consequently, she was showing gingiva on the right maxilla; there was a medial and lower movement of the whole segment. Also, because of the major Bolton discrepancy, there was no space for the right mandibular canine, and it was completely buccal with no space between the right mandibular lateral and premolar. Her chin was deficient ( eFig. 63.6 ).
Assessment
Maxillary transverse deficiency, missing tooth #10, mandibular transverse deficiency, chin anteroposterior deficiency, and dental malocclusion with crowding.
Treatment
After complete orthodontics evaluation, maxillary and mandibular Hyrax devices were installed 3 days before the surgery. The following were done:
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Right maxillary widening (7 mm) and superior repositioning (3 mm)
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Mandibular widening via distraction osteogenesis at site #27
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Chin advancement using a horizontal osteotomy at the symphyseal area (5 mm) ( eFig. 63.7 )
• eFig. 63.7 A–E, Surgical techniques for chin advancement and subsequent application of appliances to finish the orthodontics treatment.
Activation started 7 days after surgery, and after 14 days she was sent to the orthodontist for full brackets installation. Acrylic was applied over the screws to stabilize the distractors, and a plastic tooth was fixated to a bracket on either distraction site. Three months later, the appliances were removed, a transpalatal bar was installed, and full mechanics were applied to finish the orthodontics treatment within 18 months ( eFig. 63.8 ).
Eight months after surgery, a dental implant was inserted in site #10, and an immediate provisional crown was fixated ( eFig. 63.9 ). Four months later, the braces were removed, and the final crown was fabricated and installed ( eFig. 63.10 ).
