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: miesjekar@gmail.com

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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