This article reports the interdisciplinary treatment of a girl born with a complete bilateral cleft lip and palate. She had congenitally missing maxillary lateral incisors and canines and mandibular incisors, canines, and second premolars in addition to third molars. At age 11 years 2 months, she was treated with rapid maxillary expansion followed by bonding of the maxillary arch. Cranial harvested alveolar bone graft surgery was done at age 17 years 2 months. Mandibular arch treatment was started at age 19 years using single tooth implants initially as orthodontic anchorage devices and secondarily as prosthetic abutments. Teeth were placed in strategic positions for a 4 incisor fixed partial denture cemented on the 2 lateral incisor implants and screw-retained crowns on premolar implants. The maxillary arch was restored with screw-retained crowns on canine implants with lateral incisors in cantilever and pink ceramic. Two years posttreatment records at age 22 years 6 months showed long-term stability with good occlusion, facial balance, and smile esthetics.
Highlights
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An 11-year-old girl had complete bilateral cleft lip and palate and 12 missing teeth.
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Treatment included rapid maxillary expansion and bone grafts.
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Single tooth implants were used as orthodontic anchorage devices, then as prosthetic abutments.
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Two years posttreatment records at 22 years 6 months.
Cleft lip and palate deformities are among the most common birth defects, occurring in approximately 1 of every 600 births. Multidisciplinary treatment of these patients represents a real challenge and comprises different stages initiated at birth and continued into adulthood when craniofacial skeletal growth is complete. Depending on the extent of the cleft defect, treatment may start during the second week of life with presurgical infant orthopedics with nasoalveolar molding, followed by lip closure, pharyngeal flaps, maxillary expansion in the mixed dentition, alveolar bone graft surgery, orthodontic tooth alignment in the early permanent dentition, combined orthodontics and orthognathic surgery at the end of growth in severe maxillary deficiencies and restorations in cases of missing teeth. Management of children born with cleft lip and palate has evolved from multiple uncoordinated interventions from various specialists to a coordinated team approach. The orthodontist plays an important role in assisting the cleft palate team in considering treatment techniques, sequence, and timing in relation to the effect on maxillofacial growth. This case report illustrates the treatment of a bilateral cleft lip and palate patient from early adolescence to adulthood with a 2-year posttreatment follow-up. It also highlights the role of the orthodontist and the proper coordination between the cleft team members.
Diagnosis and etiology
The patient was a girl, aged 11 years 2 months, born with a complete bilateral cleft lip and palate. Her chief complaint was having unpleasant teeth and smile. Her medical history included soft tissue palate closure surgery at 2 months and lip closure surgery, right side at 6 months, and left side at 8 months. Her dental history included routine dental evaluations and restorations on permanent first molars, which showed signs of decalcification. She had retained primary teeth and a space maintainer after an early extraction of the mandibular left primary second molar. Her oral hygiene was adequate, but she had some gingival inflammation on the maxillary central incisors, partly because of the protrusion of the premaxilla and a tendency to breathe via the mouth. Only minor speech impairments could be noticed. The etiology of her malocclusion was attributed to genetic and environmental factors such as the sequelae of the cleft lip and palate birth defect and the corresponding surgical interventions.
The patient had a convex profile with a tendency to upper and lower lip protrusion, loss of nasal projection, and a short columella. From a frontal view, the face was well balanced and symmetrical, with an increased nasal base width. Mild bilateral vertical scars were apparent on the upper lip because of lip closure, and the tip of the nose looked flat. She tended to refrain from smiling fully because of excessive gingival display. She also had prominent buccal corridors on smiling owing to a transverse collapse of the maxillary arch secondary to palate closure surgery ( Fig 1 ).
Intraorally, she had an Angle Class I molar on the left side, and an edge to edge molar relationship on the right side. The upper midline was coincident with the facial midline, and the lower midline was shifted 2 mm to the patient’s right. The maxillary right premolars and primary canine were in crossbite. The maxillary central incisors showed an abnormal conical shape and were retroclined and overerupted. She had an excessive and impinging overbite. The maxillary arch was V-shaped with a protruded premaxilla and a high triangular palatal vault. The transpalatal arch width at the first molars was 26 mm, which was smaller than the average normal width of 34.5 mm. She had a total of 11 retained primary teeth: 4 in the maxillary arch (primary right lateral incisor, canines, and left second molar) and 7 in the mandibular arch (primary incisors, canines, and the right second molar). The mandibular arch was ovoid and had 8 mm of arch length deficiency with 26 mm of available space for the missing permanent incisors and canines ( Figs 1 and 2 ).
The panoramic radiograph was taken 3 months before the pretreatment records when the primary maxillary right second molar and the primary left first molar were still present. It revealed a total of 12 congenitally missing permanent teeth: the maxillary lateral incisors and canines in the cleft area and the mandibular incisors, canines, and second premolars. The third molars were also missing, and the second molars were fully erupted. The maxillary right first molar had a root canal treatment ( Fig 3 , D ).
The lateral cephalometric analysis revealed a skeletal Class II anteroposterior relationship (ANB, 6°; Wits appraisal, 4.5 mm) and a hyperdivergent facial growth pattern (FMA, 38.5°; Mp-SN, 45.5°). The maxillary central incisors were retroclined. Soft tissue analysis confirmed lower lip protrusion and weak nasal projection. The frontal cephalometric radiograph showed a symmetrical face and a transversely constricted maxillary width of 59 mm, smaller than the average normal width of JR-JL (63.2 mm) (Ricketts Rocky Mountain Analysis) ( Fig 3 ; Table ).
| Measurement | Normal | Before treatment | After treatment | Two-y posttreatment |
|---|---|---|---|---|
| Skeletal | ||||
| SNA, ° | 82 | 79 | 78.5 | 77 |
| SNB, ° | 80 | 73 | 77.5 | 75 |
| ANB, ° | 2 | 6 | 1 | 2 |
| FH-NA (maximum depth), ° | 90 | 91 | 91 | 85 |
| FH-NP (facial angle), ° | 87 | 87 | 93 | 86 |
| Wits appraisal, mm | 1 | 4.5 | −2 | 0 |
| SN-MPA, ° | 32 | 45.5 | 37 | 37 |
| FMA, ° | 25 | 38.5 | 30 | 30 |
| Mandibular length (Co-Gn), mm | 122 | 100 | 115.5 | 115 |
| Dental | ||||
| SN-U1, ° | 103 | 75 | 103.5 | 104 |
| U1-NA, ° | 22 | −4 | 25 | 25 |
| U1-NA, mm | 4 | −2 | 3.5 | 3.5 |
| L1-NB, ° | 25 | 20 | 15 | 13 |
| L1-NB, mm | 4 | 1 | 0 | 2 |
| L1-Mp, ° | 87 | 82 | 80.5 | 81 |
| L1-Apo, mm | 1 | −3 | −2 | 0 |
| U1-L1, ° | 131 | 150 | 139 | 135 |
| Soft tissue | ||||
| Facial contour angle, ° | 11 | 15 | 5 | 6 |
| Holdaway line | ||||
| Tip of nose, mm | 9 | 1 | 7 | 7 |
| Subnasal, mm | 5 | 5 | 3 | 4 |
| Upper lip, mm | 0 | 0 | 0 | 0 |
| Lower lip, mm | 0 | −3 | −3 | −3 |
| Supramentale, mm | 5 | 4 | 3 | 4 |
| Pogonion, mm | 0 | 0 | 0 | 0 |
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