|Year : 2012 | Volume
| Issue : 3 | Page : 195-200
Orthodontic-surgical treatment of repaired cleft lip and palate with maxillary hypoplasia
Ankur Gupta1, PS Raju1, Preeti Bhattacharya1, DK Agarwal1, Jaishree Garg2
1 Department of Orthodontics, Institute of Dental Sciences, Bareilly, India
2 Department of Periodontics, Institute of Dental Sciences, Bareilly, India
|Date of Web Publication||15-Oct-2012|
P S Raju
Department of Orthodontics, Institute of Dental Sciences, Pilibhit by Pass Road, Bareilly - 243 006
Source of Support: None, Conflict of Interest: None
Cleft lip and palate is a common craniofacial anomaly, requiring complex multidisciplinary treatment and having lifelong implications for affected individuals. The management starts soon after birth and involves a series of treatments during the first 20 years of life. The importance of the dentition and contribution of the orthodontist to the care of cleft patients from infancy to adulthood are presented. Close communication between orthodontists and surgeons is emphasized. The orthodontic treatment plan is developed around the anatomic, functional, and developmental needs of the patient. Despite great progress towards a better understanding of cleft lip and palate, as yet there is no accepted consensus on the management strategy. This article outlines the multidisciplinary approach to the management of the cleft lip and palate patients.
Keywords: Cleft lip, cleft palate, maxillary advancement, maxillary hypoplasia
|How to cite this article:|
Gupta A, Raju P S, Bhattacharya P, Agarwal D K, Garg J. Orthodontic-surgical treatment of repaired cleft lip and palate with maxillary hypoplasia. J NTR Univ Health Sci 2012;1:195-200
|How to cite this URL:|
Gupta A, Raju P S, Bhattacharya P, Agarwal D K, Garg J. Orthodontic-surgical treatment of repaired cleft lip and palate with maxillary hypoplasia. J NTR Univ Health Sci [serial online] 2012 [cited 2020 Apr 7];1:195-200. Available from: http://www.jdrntruhs.org/text.asp?2012/1/3/195/102454
| Introduction|| |
Cleft lip and palate (CL/P) is the most common facial malformation in all populations and ethnic groups, accounting for 65% of all head and neck anomalies.  Every day, some 700 children with cleft lip and/or cleft palate are born in the world, which means that a baby with such a cleft is born every 2 minutes or 240 000 every year.  The reported incidence varies according to geographic location, ethnicity, gender, and socio-economic status. Cleft lip and palate is most prevalent among Asians, least in Africans, and in Caucasians, its prevalence is intermediate.  An estimated incidence of 1.2 CL/P per 1000 live births was reported in Hong Kong.  These figures are underestimates due to incomplete registration. Cleft lip and palate is more common in boys, while more girls are affected with isolated cleft palates.  Clefts can occur as isolated malformations (non-syndromic clefts) and are associated with other malformations. In humans, non-syndromic clefting of the lip and palate has a multifactorial etiology and may entail a polygenic inheritance in combination with exogenous factors. There is general consensus that a multidisciplinary team approach is the optimal management strategy for CL/P patients, in order to achieve normal speech, hearing, occlusion, maxillofacial growth, appearance, and psychosocial wellbeing. However, the treatment protocol, including the appropriate timing and method of each intervention, continues to be a topic of debate. 
| Case Report|| |
A 16-years-old female with a repaired cleft lip and palate presented with a moderate skeletal class III mal-occlusion. The patient's profile was concave [Figure 1]. The lower lip was prominent, and the lips were competent. Vertical facial proportions were normal, and there were no significant asymmetries. A full complement of permanent teeth was present, except both right and left upper lateral incisors and upper left second premolar. Retained upper left 2 nd deciduous molar was present. In both centric occlusion (CO) and centric relation (CR), molar relationships was class II on left side and class I on right side, and the incisors had an anterior crossbite with a negative overjet of 3 mm. The maxillary incisors were slightly upright, while the mandibular incisors were somewhat protrusive, and upper midline was deviated by 1 mm towards left side and lower midline was coincident to the facial midline. [Figure 2] The pre-treatment cephalometric evaluation showed that the maxilla was retrusive to the cranial base (SNA 77°), and mandible was in a normal position relative to the cranial base (SNB 81°). The ANB (4°) indicated a class III skeletal relationship. The mandibular plane was normal relative to the cranial base (SN-GoGn 31°).
|Figure 1: Pre-treatment extraoral photographs; (a). Frontal, (b). Frontal smile, (c). Profile, (d). Lateral smile|
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|Figure 2: Pre-treatment intraoral photographs; (a). Frontal, (b). Right lateral, (c). Left lateral, (d). Upper occlusal, (e). Lower occlusal|
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A two-stage surgical and orthodontic treatment regimen was initiated. The aim of the pre-surgical orthodontic preparation was to correct the dental disharmonies. The main goals of the orthodontic-surgical treatment were to promote maxillary advancement for correction of the dental relationship and class III skeletal malocclusion.
The following treatment plan was developed. Maxillary and mandibular fixed appliances (pre-adjusted edgewise 0.022-inch) were used. A sequence of 0.014" to 0.018" NiTi archwires was used for the alignment and leveling of maxillary and mandibular dental arches. The intercuspation was checked by occluding the plaster models that were obtained periodically until satisfactory occlusion was attained for performing the surgery. After obtaining satisfactory intercuspation of the plaster models, soldered hooks were placed on a 0.019 x 0.025 stainless steel archwires in all inter-bracket spaces, and the patient was forwarded to orthognathic surgery [Figure 3]. The surgical procedure included maxillary advancement. Surgery was planned according to facial analysis, predictive cephalometric tracing, and preparation of the surgical guide. After surgery, the patient returned for orthodontic finishing for obtaining class II molar relationship, normal overjet and overbite, and coincident midlines. After the active treatment phase, a wraparound-type retention plate was used in the maxillary arch, and a stainless steel 3 x 3 lingual canine-to-canine retainer was placed in the mandibular arch.
|Figure 3: Pre-surgical intraoral photographs; (a). Frontal, (b). Right lateral, (c). Left lateral|
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At the end of treatment, it was observed functional occlusion, normal overjet and overbite, and adequate intercuspation, with class II molar relationship, coincident midlines, normal lateral and protrusive excursions. The cephalometric measurements showed maxillary advancement (SNA 82°), contributing to improve the patient's profile [Figure 4], [Figure 5], [Figure 6].
|Figure 4: Post-treatment extraoral photographs; (a). Frontal, (b). Frontal smile, (c). Profile, (d). Lateral smile|
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|Figure 5: Post-treatment intraoral photographs; (a). Frontal, (b). Right lateral, (c). Left lateral, (d). Upper occlusal, (e). Lower occlusal|
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| Discussion|| |
The central theme of this paper is to emphasize a comprehensive naso-maxillofacial reconstructive approach for the skeletally mature cleft lip and palate patient with midfacial retrusion, nasal deformity, mal-occlusion, and lip deformity. This approach is based on wide naso-maxillary skeletalization, making possible direct observation and repair of pathologic anatomy responsible for the deformity.
Despite successful, well-timed surgery and adequate orthodontic treatment, maxillary hypoplasia appears to be unavoidable in some patients with cleft lip and palate.  Maxillary hypoplasia in patients with cleft lip and palate is variable because of the original embryological defect, corrective surgery during infancy, and subsequent orthodontia. It occurs not only in the sagittal plane but also in the transverse and vertical planes.  Thus, maxillary osteotomy has been used to treat skeletal deformities in these patients, because the maxilla is the foundation for the lip and nose, deformities in the lip and nose cannot be repaired correctly without reconstructing maxillary deformities.
The treatment plan had 4 specific goals: 1. optimal oral health, 2. occlusal stability, 3. comfort when functioning, and 4. acceptable aesthetics. The relationship of the jaws and teeth should be analyzed to determine which segment/teeth is/are properly related to the cranial base and skeletal facial profile. The treatment goal is to maintain what is correctly aligned and change what is not. Analysis of the mounted casts is an important step. An important outcome is occlusal stability, with a focus on stable holding contacts for each tooth. Radiographic examination plays an important role as well, establishing biological health of the periodontium relative to pulpal, osseous, and structural concerns. Radiographic examination also provides analysis of skeletal relationships to aid in diagnosis and treatment. When properly treated, crossbite relationships can be very stable, predictable, and maintainable. This is possible because the teeth are not being bodily moved through osseous tissue with retained memory of periodontal ligaments and other structures. Further, stability and maintainability are achieved through stable centric occlusion contacts. 
Results have been impressive when measured in terms of improvement of self-image by the patient and general satisfaction with both the aesthetic and functional results expressed by the patient and family. As demonstrated in this class III case, with proper examination, diagnosis, treatment planning, and communication, excellent aesthetic, phonetic, and functional results can be achieved and maintained.
| Conclusion|| |
When determining if treatment for mal-occlusion is indicated, the clinician must understand how the mal-occlusion affects the patient aesthetically, functionally, and biologically, as well as any impact of treatment. It is important to consult the patient and advise when a less invasive orthodontic treatment plan may be optimal. This case report demonstrates that surgical options can be satisfactory with skeletal class III cases. The orthodontic-surgical protocol provided good maxillary incisor exposure and excellent functional occlusion, and improved the patient's profile.
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