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TRANSCRIPT
Management of Unilateral Cleft Lip and Alveolus with Orthodontic Treatment and Alveolar Bone Graft
Author name: Devina Yastani, Orthodontic Department Residence Program, Faculty of Dentistry,
University of Indonesia
Corresponding author: Miesje Karmiati Purwanegara, Orthodontic Department, Faculty
of Dentistry, University of Indonesia
Corresponding email: [email protected]
Abstract
Treatment of unilateral cleft lip and alveolus of a 10 year-old patient was conducted with
orthodontic and alveolar bone graft. He had a piercing upper central permanent incisor due to
its rotating position. Two stages of treatment was needed to achieve the alignment and
continuation of upper dental arch. First stage of treatment was to get alignment of upper
dental arch to accommodate the alveolar bone graft. Second stage was the alveolar bone graft
and finishing of the orthodontic treatment. Alveolar bone graft was aimed to give continuity
to the dental arch, let upper right lateral deciduous canine substituted the upper lateral
permanent incisor, and succeed the eruption of upper right permanent canine through the
graft.
Keywords: alveolar bone graft; orthodontic treatment; unilateral cleft lip and alveolus
Introduction
Cleft lip and palate is the most common craniofacial anomalies.1-11 Its etiologies are
multifactorial with interaction of local and environment factors in embryogenesis in
particular times.1, 2 Cleft lip and palate occur due to failure of migration or fusion between
facial prominences from week 4 to week 8 after conception. 13, 14 Cleft lip forms due to
hypoplasia of mesenchymal tissue causing fusion failure of medial nasal process and
maxillary process while cleft palate happens because of fusion failures of the palatal shelves.
12
Children with orofacial cleft need a complex and long treatment, depending on the
case severity. 1 Treatment goals of cleft lip and palate are restoring speech, hearing, facial
development, swallowing, occlusion, and esthetic.13 Management of patient is done most
effectively by an integrated team consisting of plastic surgeon, maxillofacial surgeon,
neurosurgeon, orthodontist, pedodontist, prosthodontist, peditrician, psychologist, ENT
specialist, speech pathologist, geneticist, nurse, and parents. 2, 12, 14 This case report explains
one case of unilateral cleft lip and alveolus.
Diagnosis and etiologies
The patient was a 10-year-old Indonesian boy who had a unilateral cleft lip and
alveolus with no other associated syndromes. He complained of ulcer and pain caused by
severe piercing upper right central incisor due to its rotating position.
Frontal facial photographs before treatment showed the upper lip was scarred because
of the closure of unilateral cleft lip. There was no sign of asymmetry. The lateral-view
photograph showed a slightly convex facial profile with a slightly protruded upper lip.
Intraoral images depicted ulceration of upper lip because of the extreme rotation of
upper right central incisor. The patient had bad hygiene and bad gingival health with no tooth
mobility, shallow palate and average tongue. Permanent teeth which had not erupted well
were upper right canine, upper right second molar, upper right third molar, upper left canine,
upper left second molar, upper left third molar, lower left second molar, lower left third
molar, lower right second molar, lower right third molar. In addition, the upper right lateral
incisor did not erupt. The patient had deciduous upper right canine and upper left canine.
Molar relationship was class one on both sides. He had 0 mm overjet and 1 mm overbite,
with deep curve of Spee, coincide upper and lower midline. Extraoral and intraoral images
were shown in fig 1.
Fig 1. Pretreatment facial and intraoral photographs. Scarring of upper lip is seen due to previous repair
Panoramic image displayed mixed dentition. It was also observed the permanent
upper right lateral incisor did not have good apical growth. The panoramic showed alveolus
cleft at the apical of upper left lateral incisor. The occlusal analysis showed a radiolucent area
in the apical region of upper lateral incisor (fig 2).
Fig 2. Pretreatment panoramic and occlusal images show alveolus cleft at apical region of upper right central incisor
The cephalometric analysis showed that the patient has a skeletal class II relationship
with a retrusive mandible. He had hyperdivergent facial development, mandible
development, and lower third facial development with a normal inclination of upper and
lower incisor, but the position of upper incisor was retrusive (fig 3, table). His upper and
lower lips were protrusive. There were no signs of any temporomandibular disorders.
Fig 3. Pretreatment lateral cephalometric radiograph
Table. Values of pretreatment and posttreatment lateral cephalometric analyses
Horizontal skeletal parameter
Angle/Distance Mean ± SD Pretreatment Posttreatment
SNA 82°±2° 80° 80°
SNB 80°±2° 73° 74.5°
ANB 2°±2° 7° 5.5°
The Wits F: AO = BO M: BO 1 mm in front of AO
AO in front of BO 1.5 mm AO in front of BO 1 mm
Facial angle 87°±3° 84° 84°
Angle of convexity 0°±2° 12.5° 10°
Pg-NB 4 mm±2 +1.5 mm +1.5mm
Vertical skeletal parameter
Angle Mean ± SD Pretreatment Posttreatment
Facial axis 90°±3.5° 84° 80°
Y-axis 60°±6° 71.5° 62.5°
SN-MP 32°±3° 43° 40°
SN-PP 8°±3° 12° 12°
PP-MP 27°±4° 31.5° 26.5°
Dental parameter
Angle/Distance Mean ± SD Pretreatment Posttreatment
Interincisal angle 130°±2° 132° 117°
UI-SN 104°±6° 98° 108.5°
UI-NA 4 mm±2 -1 mm +4.5mm
UI-Apg 4 mm±2 +4 mm +7mm
LI-MP 90°±4° 90° 94.5°
LI-Apg 2mm±2 +5 mm +6mm
LI-NB 4 mm±2 +8.5 mm +9mm
Soft tissue parameter
Distance Mean ± SD Pretreatment Posttreatment
U lip – E line 1 mm +3 mm +1.5mm
L lip – E line 0 mm +7 mm +7mm
Treatment plan
Patient needs a comprehensive, integrated treatment which consists of orthodontist,
pedodontist, periodontist, maxillofacial surgeon, and plastic surgeon. Two stages treatment
for the upper arch and one stage treatment for lower arch are needed. Aligning and leveling
will be done in lower arch. First stage of the upper arch is to eliminate the ulcerating contact
of the rotating first incisor to the labial mucosa by using molar band, quad helix, and lip
bumper. Second stage is to establish good arch alignment by the bonding of preadjusted
braces and continuity of alveolar bone by alveolar bone graft. Orthodontic treatment with
attached braces starts if the position of upper right central incisor is more palatal so that it can
be included in aligning leveling progress. After upper arch is aligned and leveled, and
overcorrected overjet is achieved, then the alveolar bone graft can be conducted. The space
for upper right and left permanent canine are planned at aligning leveling stage. Finishing and
retention using essix is planned.
Treatment progress
Before orthodontic treatment, patient was consulted to pedodontist for ulceration
treatment, scaling, and reinforcement of his dental health education. Orthodontic treatment
was started on August 2013 with MBT braces with slot .022”. One week after that, in the
upper arch, molar band with triple tube and lingual sheath were cemented for accommodating
the usage of lip bumper and quad helix.
At first month of treatment, was inserted. Initially the quad helix was passive in order
to make patient comfortable with the device. At third month of treatment, quad helix was
activated ± 3 mm on both side.
Fig 4. First month of treatment, lip bumper and quad helix had been inserted
In the fourth month, upper braces were inserted because of more favorable position of upper
right central incisor. Quad helix was also activated ± 3 mm at each side.
In the fifth month of treatment, a 1 mm of anterior overjet and posterior overjet were
achieved. Quad helix was still activated to get a bit overcorrection. In the seventh month
treatment, upper lateral canine was erupting, so extraction of upper lateral deciduous canine
was done. Aligning leveling progress was carried until nickel titanium .017” x .025” together
with the activation of quad helix until 12 month of treatment.
In the twelveth month of treatment, a stainless steel .017” x .025” was inserted and
quad helix was in passive mode. After the alignment of upper arch was obtained, alveolar
bone graft was planned. To ease the procedure of alveolar bone graft, the wire was cut at
distal upper right central incisor and mesial of upper right deciduous canine (fig 5). When
patient was 11 years and 10 months, alveolar bone graft was carried at the department of
plastic surgery of Cipto Mangunkusumo hospital. Iliac crest was taken as the source of the
bone graft. Upper lateral permanent incisor was also taken out at that procedure. Quad helix
was still used to maintain the expansion of arch form (fig 6).
Fig 5. Intraoral images before alveolar bone graft was carried out
Fig 6. Procedure of alveolar bone graft: A-C, The harvesting of iliac crest; D, Intraoral images after the graft was
inserted
A B C D
Treatment results
The total orthodontic treatment (ongoing) together with alveolar bone graft has been
conducted for 45 months. The patient is having his upper right canine erupting through the
graft. Chief complain of patient which was to straighten the rotating tooth has disappeared.
Patient has reducing facial convexity. Position of upper lip is more aesthetic as it move
backward. Patient’s smile has become more aesthetic because it shows his upper incisors.
Comparison of extraoral images before and after treatment is shown at fig 7.
Fig 7. Pretreatment and posttreatment extraoral images
Sagittal parameter has decreased to 5.5° (ANB angle). SNA angle is stable (80°)The
superimposition of lateral cephalometric is shown at fig 8. The posttreatment cephalometric
values is shown at table.
Fig 8. Superimposition of cephalometric tracings (blue line, pretreatment; red line, posttreatment)
Overjet and overbite become 2 mm. Crossbite at anterior right buccal segment is
corrected. His upper right canine is successfully erupting through the graft. The upper right
deciduous canine has substituted the upper right lateral permanent incisor. Curve of Spee has
flatten. Pretreatment and posttreatment of intraoral images are shown in fig 9.
Fig 9. Pretreatment and posttreatment intraoral images
The upper cast shows sagittal expansion. The length of upper arch measures from line
perpendicular to contact point between upper central incisors to the line drawn from mesial
permanent upper first molars (fig 10). The length of upper arch has been adding up from 19
mm to 26 mm for 10 months of treatment before alveolar bone graft and to 27 mm a month
after alveolar bone graft.
Fig 10. A, Arch length (continuous line); B, Ten months before alveolar bone graft; C, One month after
alveolar bone graft
Panoramic image at 7 months after bone graft shows relatively parallel root with
normal alveolar bone height at graft site. In addition, occlusal image shows 90% of dense at
graft site (Fig 11).
Fig 11. Posttreatment panoramic and occlusal images
Discussion
This case report shows the success of orthodontic treatment combined with alveolar
bone graft to a unilateral cleft lip and alveolus patient. This patient came with a chief
complain which was the piercing tooth. He has crossbite at his anterior right and left segment.
Scar which was caused by labiaplasty resulted the anterior and posterior constriction of upper
arch.
This case needed two stages of treatment for upper arch. Main goal of first stage was
to correct the ulcerating position of upper right permanent incisor and to achieve a good arch
to accommodate alveolar bone graft. The second stage was achieving continous alveolar bone
A B C
at the cleft side and finishing. Quad helix was used to expand the upper arch. It is a slow type
of expansion, but Herold (1989) reported that there was no expansion differences between
rapid palatal expansion and slow palatal expansion.15 Besides, the transversal deficiency did
not require significant expansion, so the quad helix was chosen.
Lip bumper usage was to cover the upper lip from the piercing upper central
permanent incisor and to diminish constriction in anterior segment. The force resulted from
scar was diminished so that it accommodated the alveolar bone to grow anteriorly. This was
proven by the stable SNA angle, which was 80°. Ross (1993), Ozturk and Cura (1996), and
Moreira (2014) reported the more retrusive maxilla as patient unilateral cleft lip and palate
ages. After two years and 5 months of treatment, the value of SNA did not decrease. Another
good evidence showed that the upper arch length was increasing.
Patient had alveolar bone graft as his treatment when his maxilla was expanded to
give better surgical access and to maximize bone graft to be put. 16 The panoramic and
occlusal images showed good density at cleft site. Some literatures said the success of bone
unity following bone graft was 58.3% - 100% at 12.5 weeks – 48.4 weeks time.17 Six months
following alveolar bone graft, the upper left deciduous canine was moved slowly to the graft
site.
The more retrusive position of upper lip was achieved and patient’s smile was more
aesthetic because it showed more upper incisor. The overbite and overjet was 2 mm. The
current orthodontic treatment was to align the erupting upper right central permanent incisor.
Conclusion
This case report shows that interdisciplinary treatment is needed to treat a unilateral
cleft lip and alveolus patient to achieve good occlusion.
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