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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 8  |  Issue : 3  |  Page : 159-162

Orthodontic and prosthodontic management of an adult patient with unilateral cleft lip and palate


Department of Dentistry, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Sapna Singla
Department of Dentistry, Government Medical College and Hospital, Sector-32, Chandigarh - 160 033
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-4003.191732

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  Abstract 

Cleft lip and palate is a common congenital malformation. Individuals born with this type of deformity, face number of challenges such as facial esthetics, hearing impairment, anatomical deformities to name a few. These patients require various treatments involving a multidisciplinary team such as prosthodontists, orthodontists, cosmetic dentists and surgeons. This report describes a case of orthodontic and prosthetic rehabitilation of an adult patient with unilateral cleft lip and palate.

Keywords: Cleft lip and palate, obturator, orthodontics


How to cite this article:
Singla S, Pandher PK, Lehl G, Talwar M. Orthodontic and prosthodontic management of an adult patient with unilateral cleft lip and palate. Indian J Dent Sci 2016;8:159-62

How to cite this URL:
Singla S, Pandher PK, Lehl G, Talwar M. Orthodontic and prosthodontic management of an adult patient with unilateral cleft lip and palate. Indian J Dent Sci [serial online] 2016 [cited 2022 Jul 2];8:159-62. Available from: http://www.ijds.in/text.asp?2016/8/3/159/191732


  Introduction Top


Cleft lip and cleft palate is one of the most common congenital malformations affecting the face and the jaws with incidence varying between 1:500 to 1:2500 live births.[1],[2] These patients suffer from multiple problems such as facial disfigurement, dental malocclusion due to missing and malformed teeth, compromised mastication, improper speech, and nasal regurgitation.[3] For the long-term benefit of these patients, multidisciplinary approach is required which involves orthodontist, surgeons, prosthodontists, and restorative dentists.[4],[5],[6] Although complicated as well as invasive treatment of adult patients with orofacial clefts involving orthognathic surgeries and other treatments such as alveolar bone grafting and endosseous implants have been reported by several authors,[7],[8] very few have reported conventional orthodontic and prosthodontic treatment for adult patient with unilateral cleft lip and palate.[9] Therefore, in this article, we report a case of an adult patient with unilateral cleft lip and palate treated with orthodontic and prosthodontic treatment with a conventional approach.


  Case Report Top


A 35-year-old male patient with unilateral cleft lip and palate reported to the Department of Dentistry with a chief complaint of unpleasant smile. The patient was wearing a removable obturator appliance, but he was not satisfied with it. He presented a history of lip repair at the age of 1 year and palate repair at the age of 3 years. Extraorally, he had apparently symmetrical, mesoprosopic face, straight profile, competent lips, and a scar over the right side of upper lip. On intraoral examination, the patient had unilateral repaired cleft lip and palate with a residual palate-alveolar cleft defect and oronasal fistula on the right side. Dentitionally, patient had Class II molar relation on the right side and Class I molar relation on the left side, with missing right maxillary lateral incisor at the site of cleft as well as missing left maxillary lateral incisor, and both the maxillary central incisors being shifted toward the left side of cleft [Figure 1],[Figure 2],[Figure 3].
Figure 1: Pre-treatment extraoral and intraoral photographs.

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Figure 2: Pre-treatment study models.

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Figure 3: Pre-treatment lateral cephalogram and orthopantomogram.

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Treatment objective

The primary objective was to replace the missing anterior teeth, correction of crowding, and improvement of patient's smile.

Treatment alternatives

Based on these treatment objectives, three plans were decided. The first treatment plan was surgical closure of oronasal fistula followed by preorthodontic alveolar grafting, moving of maxillary right central incisor into the grafted area, correcting the midline, expanding and aligning the arches, and later on implant-supported prosthesis for both the right and left maxillary lateral incisors and ending up in Class I molar relation on both sides. However, the patient was not ready for such an extensive treatment because of the time factor and financial reason. The second plan was to correct crowding by the expansion of the arches and redistribution of available space, accepting the right maxillary central incisor as left maxillary central incisor, recontouring the left maxillary central incisor as left lateral incisor, and later replacing the right maxillary central and lateral incisor prosthetically. Although this type of treatment plan did not require any extractions but there were chances of exposing the root of maxillary right central incisor to the alveolar cleft area. The third treatment plan was to extract both the maxillary premolars with no extraction in the lower arch, accepting the right maxillary central incisor as left maxillary central incisor, recontouring of left maxillary central incisor as left lateral incisor, widening of the cleft space by distalizing the right maxillary canine to create enough space for prosthetically accommodating both right maxillary central and lateral incisors, and close the excess spaces mainly by mesialization of maxillary molars and thus ending up in Class II molar relation. Hence, the third treatment plan was chosen, and informed consent of the patient was taken. Treatment was started with extractions of both maxillary second premolars.

Treatment progress

A 0.018” preadjusted edgewise appliance (Roth prescription) was used. Initial alignment and leveling were done with 0.014” NiTi archwire in both maxillary and mandibular arches. After intial alignment and leveling, maxillary left central incisor was contoured as lateral incisor and the right maxillary canine was distalized with 0.016” × 0.022” stainless steel archwire and intramaxillary elastic chain. Since space for the right maxillary central and lateral incisor was little more than required, and it was decided to widen the right maxillary central incisor (so called left central incisor) with composite build up mesiodistally and thereafter in the remaining space, the prosthetic replacements of the right maxillary central and lateral incisors were attached to the archwire [Figure 4]. After that, the remaining excess spaces were closed by mesialization of both maxillary first and second molars. The final relation was Class II, and the patient was satisfied with the result [Figure 5],[Figure 6],[Figure 7]. The patient was given obturator cum retainer cum denture in the upper arch and canine to canine lingual bonded retainer in the lower arch.
Figure 4: Treatment progress photographs. (a) Space in the anterior region after distalization of right maxillary canine. (b) Left maxillary central incisor after composite build up. (c) Prosthetic replacements attached to the archwire.

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Figure 5: Post-treatment extraoral and intraoral photographs.

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Figure 6: Post-treatment study models.

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Figure 7: Post-treatment lateral cephalogram and orthopantomogram.

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Treatment results

All the objectives were met. Patient had well-aligned arches, Class II molar relation, and pleasing smile.


  Discussion Top


Although surgical closure of the defect and alveolar bone grafting in this patient would have provided support and elevation of the alar base on the cleft side, construction of a continous arch form, and alveolar ridge.[10] However, there are strong controversies regarding the recurrence of the oronasal fistula and the timing and age of graft. It has been stated that the overall failure rate of oronasal fistula closure was around 37% and increased as high as 65% in the second or further procedures.[11] Several studies suggest that bone graft success decreases if performed after the eruption of permanent canine into the cleft site.[10],[12] It has also been mentioned that once teeth have erupted in the cleft site, their periodontal support will not improve with a bone graft; instead, the height of the crest of alveolar bone will resorb to its original level.[13] Hence, our patient declined surgical approach both due to its potential failure risk as well as its high cost. Moreover, patient wanted treatment of a shorter duration, and our treatment lasted for 20 months. At the end, the patient was extremely satisfied with the results. Results were maintained at the retention follow-up [Figure 8].
Figure 8: Eighteen months of postretention.

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  Conclusion Top


Despite recent advances in bone grafting and implants, patients in whom this could not be the treatment option due to certain reasons, orthodontics followed by conventional prosthodontic treatment can yield satisfactory results both from esthetic as well as from functional point of view.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gundlach KK, Maus C. Epidemiological studies on the frequency of clefts in Europe and world-wide. J Craniomaxillofac Surg 2006;34 Suppl 2:1-2.  Back to cited text no. 1
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2.
Gorlin RJ, Cohen MM Jr., Hennekam RC. Syndromes of the Head and Neck, 4th edition: United Kingdom: Oxford University Press; 2001.  Back to cited text no. 2
    
3.
Ksheerasagara P. Non surgical management of adult cleft palate patient. J Indian Orthod Soc 2012;46:223-7.  Back to cited text no. 3
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4.
David M, Saba SB, Delatte M, De Clerck H. Multidisciplinary treatment of an adult patient with a labiopalatal cleft. J Clin Orthod 2000;34:667-70.  Back to cited text no. 4
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5.
Reisberg DJ. Dental and prosthodontic care for patients with cleft or craniofacial conditions. Cleft Palate Craniofac J 2000;37:534-7.  Back to cited text no. 5
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6.
Sapp BB Jr., Quinn GW, Pickrell KL. Treatment of cleft lip and palate patients. J Prosthet Dent 1972;28:66-76.  Back to cited text no. 6
    
7.
Kawakami S, Yokozeki M, Horiuchi S, Moriyama K. Oral rehabilitation of an orthodontic patient with cleft lip and palate and hypodontia using secondary bone grafting, osseo-integrated implants, and prosthetic treatment. Cleft Palate Craniofac J 2004;41:279-84.  Back to cited text no. 7
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8.
Kearns G, Perrott DH, Sharma A, Kaban LB, Vargervik K. Placement of endosseous implants in grafted alveolar clefts. Cleft Palate Craniofac J 1997;34:520-5.  Back to cited text no. 8
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9.
Acar O, Kaya B, Saka M, Yuzugullu B. Prosthetic rehabitilation of cleft lip and palate patients using conventional methods: A case series. Int J Prosthodont Restor Dent 2013;3:120-4.  Back to cited text no. 9
    
10.
Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 1986;23:175-205.  Back to cited text no. 10
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11.
Abdali H, Hadilou M, Feizi A, Omranifard M, Ardakani MR, Emami A. Recurrence rate of repaired hard palate oronasal fistula with conchal cartilage graft. J Res Med Sci 2014;19:956-60.  Back to cited text no. 11
    
12.
Turvey TA, Vig K, Moriarty J, Hoke J. Delayed bone grafting in the cleft maxilla and palate: A retrospective multidisciplinary analysis. Am J Orthod 1984;86:244-56.  Back to cited text no. 12
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13.
Graber TM, Vanarasdall RL, Vig KW, editors. Orthodontics: Current Principles and Techniques. 4th ed. St. Louis: Elsevier, Mosby; 2005.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


This article has been cited by
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APOS Trends in Orthodontics. 2017; 7: 101
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