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CASE REPORT
Year : 2013  |  Volume : 2  |  Issue : 4  |  Page : 302-304

Management of oronasal fissure in an adolescent with cleft lip and palate


1 Department of Orthodontics and Dentofacial Orthopaedics, Army College of Dental Sciences, Secunderabad, India
2 Department of Prosthodontics, Lenora Dental College, Rajamundry, Andhra Pradesh, India
3 Department of Prosthodontics, Al Badar Dental College, Gulburga, Karnataka, India

Date of Web Publication26-Nov-2013

Correspondence Address:
T Harini
Department of Orthodontics and Dentofacial Orthopaedics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.122181

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  Abstract 

Successful treatment of cleft lip and palate requires a multidisciplinary approach from birth to adulthood. This article discusses the problem based diagnosis and treatment approach in an adolescent with a repaired cleft lip and untreated cleft palate. A treatment plan was developed to address the chief complaint of the patient. Maxillary expansion was done with a bonded hyrax screw rather than a quad helix, so as to shorten the pre-surgical treatment time followed by surgical closure of the oronasal fissure.

Keywords: Cleft lip, cleft palate, oronasal fissure


How to cite this article:
Harini T, Reddy S S, Reddy T J, Reddy P V, Reddy G J, Reddy S. Management of oronasal fissure in an adolescent with cleft lip and palate. J NTR Univ Health Sci 2013;2:302-4

How to cite this URL:
Harini T, Reddy S S, Reddy T J, Reddy P V, Reddy G J, Reddy S. Management of oronasal fissure in an adolescent with cleft lip and palate. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Mar 28];2:302-4. Available from: http://www.jdrntruhs.org/text.asp?2013/2/4/302/122181


  Introduction Top


Cleft lip and palate is considered to be one of the most common orofacial defects. There is an ethnic variation [1],[2] in the prevalence of this deformity, with the mongoloids having the highest incidence and the negroid race reported to have the least incidence. The incidence of cleft lip and palate in Indians is 1 in 600-1000 live births. [3] These clefts either bilateral or unilateral require a comprehensive treatment from birth to adulthood i.e., around 10 weeks to around 20 years of age. Recently, the concept of problem based diagnosis and treatment plan is being followed in all the fields of medicine. The key to a successful rehabilitation depends upon flexibility in terms of treatment options and multidisciplinary approach. The treatment starts at birth, with the cleft lip repair done by following the rule of 10's i.e., at the age of around 10 weeks, weight of around 10 pounds and the Hb% of 10 g. [4] The rational is that in an infant differentiating the various muscles is difficult right after birth and baby should be able to take the general anesthesia. This is followed by palatal repair between 12 and 18 months to facilitate normal speech, hearing and swallowing. [5],[6] During the primary dentition period a check is maintained on the timing of the eruption of primary teeth. During the mixed dentition period all precautions to control the development of a severe crossbite are taken. The expansion of the palate is recommended before the placement of alveolar graft, which coincides with the time of eruption of the permanent canine followed by a facemask therapy to protract the deficient maxilla. In the permanent dentition period, comprehensive orthodontic treatment and full mouth rehabilitation is planned. [7]

This article discusses the treatment of a patient with an incomplete cleft of the palate and an oronasal fissure.


  Case Report Top


A male patient named B.S., aged 15 years, reported with a chief complaint of nasal regurgitation of fluids from the oral cavity. He had a history of operated cleft lip at around the age of 5 months. Patient had no history of repair of palate. Patient presented with an asymmetric nose, scar on the right part of the upper lip, had a concave profile with underdeveloped maxilla and prognathic mandible with a vertical growth pattern. On intraoral examination 22 was missing, 11 was rotated and 13 was erupted adjacent to the cleft area and 53 was over retained. A supernumerary tooth was found in the palate adjacent to the cleft area. In occlusion, anterior and posterior crossbite was seen. Hard palate presented with an oronasal fissure [Figure 1]a and b. On radiological examination, there was a cleft of the alveolus and hard palate. No clefting was seen in the soft palate.
Figure 1:

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The problem list consisted of:

  • Oronasal fissure
  • Multiple missing upper anterior teeth
  • Skeletal Class III with maxillary retrognathism and mandibular prognathism


The patient needed a comprehensive treatment involving:

  • Expansion of the maxilla and
  • Alignment of the upper and lower arches
  • Orthognathic surgery to correct skeletal Class III.


As the patient was still in the growing age with 5-10% of growth remaining, comprehensive orthodontic treatment along with an orthognathic surgery and full mouth rehabilitation with a fixed prosthesis was differed until the growth of the patient was over. The growth potential was elicited by evaluating the development of cervical vertebrae. The point was in the maturation stage, with 5-10% of adolescent growth expected. Hence, the treatment goal was to attend to the chief complaint and to surgically close the oronasal fissure. For that purpose, an upper arch expansion was planned before the surgery, as the scarring that could occur after the surgical closure of the palate may not allow for the proper expansion of the palate. The amount of expansion required was calculated by using the Moyer's table to predict the transverse dimension of maxilla for that age. The amount of expansion required was calculated to be 9 mm. Every two turns of the expansion screw would give 1.25 mm of space. So, expansion was planned at the rate of one turn in the morning and one in the evening, for 2 weeks. The supernumerary tooth adjacent to the cleft was extracted before the bonding of the hyrax screw to avoid any interference during expansion and the presence of this could compromise the post-surgical healing.

A bonded hyrax screw was bonded on to the premolars and the molars. A hyrax screw was preferred to a quad helix, as it could reduce the total treatment time in this case. The activation schedule was one turn in the morning and one turn in the evening [Figure 2]. An over correction was done to compensate for any relapse that could occur because of the contraction of the scar tissue. Retention of 3 months was given to stabilize the dentoalveolar changes. Patient was then operated for the oronasal fissure by "Z" plasty under general anesthesia. Post surgically, the patient was advised by the surgeon not to wear the retention plate for a period of 2 weeks, to prevent any irritation to the palatal mucosa. The oronasal fissure was eliminated totally and the patient had no regurgitation of fluids into the nasal cavity. A maxillary splint was placed to aid in the retention [Figure 3]a and b. Post surgically some loss of transverse expansion occurred but crossbite correction remained stable [Figure 4]a and b.
Figure 2: Occlusal view of maxilla showing the bonded hyrax screw

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Figure 3:

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Figure 4:

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  Conclusion Top


The treatment of cleft lip and palate patient involves a multidisciplinary approach and follow-up right from birth to adulthood. The key to a successful rehabilitation depends on flexibility in terms of treatment options and appliances used.

 
  References Top

1.Chapman CJ. Ethnic differences in the incidence of cleft lip and/or cleft palate in Auckland, 1960-1976. N Z Med J 1983;96:327-9.  Back to cited text no. 1
    
2.Chung CS, Myrianthopoulos NC. Racial and prenatal factors in major congenital malformations. Am J Hum Genet 1968;20:44-60.  Back to cited text no. 2
    
3.Sekhon PS, Ethunandan M. Congenital anamolies associated with cleft lip and palate - An analysis of 1623 consequetive patients. J Oral Maxillofac Pathol 2012;16:64-72.  Back to cited text no. 3
    
4.Mars M, Houston WJ. A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J 1990;27:7-10.  Back to cited text no. 4
    
5.Precious DS. Cleft lip and palate. Fonseca's Oral and Maxillofacial Surgery. Vol. 6. Ch. 3. Philadelphia: WB Saunders Company; 2000. p. 27-59.  Back to cited text no. 5
    
6.Markers AF, Preciuos DS. Secondary surgery for cleft lip and palate. In: Booth PW, Hausaman JE, Schendel S, editors. Maxillofacial Surgery. ch. 29. Churchill Livingstone, Edinburgh: 1999.  Back to cited text no. 6
    
7.Precious DS, Delaire J. Surgical considerations in patients with cleft deformities. In: Bell WH, editor. Modern Practice in Orthognathic and Reconstructive Surgery. Vol. 1. Ch. 14. Philadelphia: Saunders; 1992.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
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Case Report
Conclusion
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