The oral rehabilitation of patients with cleft lip and palate is a challenge. The aim of this case report was to underline the importance of a sequential interdisciplinary approach to correct functional problems and improve facial esthetics for a patient with unilateral cleft lip and palate. Few clinical reports have described this treatment in a teenager. The patient, a girl, age 12.6 years, had a complete right cleft lip and palate with a Class II molar tendency and a full Class II canine relationship on the right side, and a full Class II molar relationship with a canine Class I on the left side. Transposed, impacted, and anomalously shaped teeth and crowding added to the patient’s problems. Treatment included maxillary expansion and maxillary and mandibular extractions. An interdisciplinary approach was necessary to achieve proper occlusion and better esthetics.
Highlights
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Oral rehabilitation of patients with cleft lip and palate is challenging.
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Interdisciplinary approach is needed to correct functional problems and improve esthetics.
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Good diagnosis and proper treatment plan are necessary.
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Good interdisciplinary cooperation and patient motivation were keys to success.
Cleft lip and palate is the most common congenital craniofacial deformity with a higher frequency in Asian people than in other races. These anomalies are the result of genetic and environmental factors and can be 1 feature of various genetically determined syndromes. Because of the failure of fusion between the medial nasal and maxillary processes in the primary palate (lip and premaxilla) or the palatal units in the secondary palate, clefts can occur from the fourth to the twelfth weeks of gestation.
Clefts can be bilateral or unilateral (UCLP) and incomplete or complete according to their severity. UCLP is the most frequent cleft, with a frequency of 33% and a separation of the upper maxilla into greater (noncleft side) and lesser (cleft side) segments.
The deficiency of maxillofacial growth in patients with UCLP is related to various factors including lack of tissues and intrinsic growth potential as well as the early reconstructive surgery.
Thus, the deficiency of maxillofacial growth in the cleft population may be a result of the cleft or the repairing surgery.
However, cleft lip and palate affects not only craniofacial but also dentoalveolar development. Thus, dental abnormalities such as hypodontia, malformations, and abnormal eruption patterns frequently occur more often in cleft patients than in the noncleft population.
The lateral incisor bud develops in the region of the dentoalveolar cleft and is sensitive to developmental disorders. A congenitally missing maxillary lateral incisor on the cleft side is the most common finding in cleft patients, and a supernumerary tooth in the cleft region is the second most frequent anomaly.
In addition, other tooth alterations can occur in location (mesial or distal to the cleft), shape (pegged or conical teeth), size (microdontia), and time of formation and eruption.
These anomalies create esthetic concerns and can also cause functional, periodontal, and restorative problems.
For all these issues, UCLP patients require interdisciplinary treatment including occlusal rehabilitation to restore their functional and esthetic needs, with the main goal to obtain stability and prevent relapse and significant disadvantages in their social lives. However, due to their complexity, the outcome of these treatments differs widely.
The purpose of this clinical case report was to point out the interdisciplinary approach in a teenaged patient with UCLP and a complex problem list.
Diagnosis and etiology
The patient was a Sri Lankan girl, age 12.6 years, in the late mixed dentition with a UCLP on the right side that had been surgically treated at 6 months of age (lip), 12 months of age (soft palate), and 18 months of age (hard palate), according to our protocol.
The patient was unhappy with her irregular smile, and her face was slightly asymmetric. Her profile was convex with a retruded upper lip, a reduced nasolabial angle, and a protruded lower lip.
The occlusion showed a Class II molar tendency with a full Class II canine relationship on the right side and a full Class II molar relationship with a canine Class I on the left side. The maxillary arch had a bilateral crossbite with a lower midline deviation. Overbite and overjet were decreased. The maxillary incisors were rotated toward the cleft side, the maxillary right canine was buccally ectopic, and both deciduous canines were still present. The patient had severe crowding of about 10 mm in the maxillary arch, whereas mild crowding of 4 mm was observed in the mandibular arch ( Figs 1 and 2 ). The periodontal examination showed a good status of the dentition.
The panoramic x-ray showed included, transposed, and anomalous lateral incisors, impacted maxillary left canine, and a severely mesio-inclined mandibular left second molar. Almost all teeth had short roots, but no root resorption was detected.
The lateral cephalometric evaluation showed a skeletal Class I malocclusion (ANB, 3.5°) with a vertical growth pattern (SN/GoMe, 39°), retroclined maxillary incisors (1/SN, 94°), and proclined mandibular incisors (IMPA, 100°) ( Fig 3 ).
The patient’s medical and dental histories were unremarkable, with no family occurrences reported. No previous orthodontic treatment had been performed, and no signs or symptoms of temporomandibular joint disorder during mandibular movement were reported.
Treatment objectives
This patient had many problems to be corrected: expansion of the constricted maxillary arch, correction of the midline deviation, control of vertical growth, correction of maxillary and mandibular crowding and the molar and canine relationships, achievement of good overbite and overjet, extraction of the included, transposed, and anomalous maxillary lateral incisors, repositioning of the impacted maxillary left canine, uprighting of the mandibular left second molar, and improvement of the smile and, as much as possible, the face and profile.
Treatment objectives
This patient had many problems to be corrected: expansion of the constricted maxillary arch, correction of the midline deviation, control of vertical growth, correction of maxillary and mandibular crowding and the molar and canine relationships, achievement of good overbite and overjet, extraction of the included, transposed, and anomalous maxillary lateral incisors, repositioning of the impacted maxillary left canine, uprighting of the mandibular left second molar, and improvement of the smile and, as much as possible, the face and profile.
Treatment alternatives
Before starting treatment, we considered the following options, all including maxillary expansion and deciduous canine extractions.
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Treatment with extractions of the maxillary lateral incisors and mandibular first premolars. In the maxillary arch, the lateral incisors needed to be extracted because they were included, transposed, and anomalous and replaced by the canines; the canines would be replaced by the first premolars. Coronoplasty was required for the maxillary canines and premolars. In the mandibular arch, extraction of the first premolars was needed to resolve the crowding (4 mm), improve the incisor inclination (IMPA, 100°), and correct the dental Class II relationship.
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Treatment with extractions of maxillary lateral incisors along with first premolars and mandibular second premolars. In this option, the included, transposed, and anomalous maxillary lateral incisors would e extracted and replaced with a fixed prosthesis or implants, whereas extraction of the maxillary first premolars and mandibular second premolars would allow for the correction of the Class II relationship, the maxillary and mandibular crowding, and the incisor proclination.
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Orthodontic-surgical treatment with needed extractions when the patient is an adult.
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No treatment if it is not accepted by the patient’s parents.
Treatment progress
The first option seemed to be the easiest and most rational choice considering the occlusion features and the patient’s expectations.
The treatment was performed in several stages: (1) maxillary expansion, (2) extractions of the maxillary deciduous canines, (3) alignment of the maxillary central incisor and derotation of the mandibular second premolar, (4) repostioning of the maxillary left canine and uprighting of the mandibular left second molar, (5) levelling of the maxillary arch and extraction of the mandibular first premolar, (6) extraction of the maxillary included lateral incisor, (7) closure of the maxillary and mandibular spaces, (8) finishing, and (9) retention.
The treatment started with a bonded maxillary expander to gain space in the maxillary arch and to control the vertical growth pattern.
After few months, the maxillary deciduous canines were extracted, and 0.018 × 0.025-in Alexander fixed appliances were applied; alignment of the maxillary central incisors was started with a 0.014-in nickel-titanium archwire, and the maxillary left canine was erupting palatally. In the mandibular arch, instead, a lingual arch and second premolar brackets were applied to achieve derotation ( Fig 4 ). Then the maxillary right canine was repositioned with a 0.016-in nickel-titanium archwire, and a 0.016-in stainless steel sectional wire was used to maintain the alignment of the central incisors. In the mandibular arch, a sectional wire with an open-coil spring was applied to upright the left second molar. It was severely mesio-inclined, impacted under the first molar, and constricted by the third molar ( Fig 5 ). Uprigthing was achieved after 6 months, as shown by the panoramic x-rays ( Fig 6 ). After 1 year, the maxillary expander was removed, and both arches were fully bonded. In both arches, levelling was performed with 0.017 × 0.025-in nickel-titanium archwires. The maxillary left canine was moved to the lateral incisor position; the mandibular first premolars were extracted, and the canines began to be retracted.
