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Cleft palate
CLEFT REPORT HERBERT
D. JAYNES,
PALATE OF
A
CASE
D.D.S., ATLANTA,
GA.
T
HE patient, C. B., was a white girl, 21 years of age, March, 1948. DiagnosB.-The patient presented Class I (Angle) malocclusion, a direct result of complete cleft of both hard and soft palates and lip on the left side, both palates and lip having been successfully closed by surgery. The mandible could be considered of normal size, development, and position. Intraoral radiographs revealed all teeth present in the mandibular arch with both third molars mesioangular impactions ; left maxillary first premolar and lateral incisor and right canine were congenitally missing. Only root of left maxillary central incisor remained in the cleft. Intraoral radiographs also revealed acceptable calcification of teeth and supporting alveolar bone, and absence of periodontal and periapical disturbance. This case exemplified the most typical cleft palate maxillary arch form and tooth malpositions, that is, the arch was V-shaped with apex forward; maxillary left -canine and first premolar and right central and lateral incisors were in complete linguoversion. The maxillary left second molar was in complete buccoversion. History and General Clinical Picture.-General physical development was good. There was no history of general illness throughout life other than mild childhood diseases : measles at 7 years, whooping cough at 10 years; otherShe had cod-liver oil and plenty wise she had always enjoyed good health. of fresh orange juice as a child. She always had milk in sufficient quantit,y. Mental health was good and she had ambitions and outlook of a normal 21year-old girl. Mother had normal palate but cleft of lip on the same side as the patient (left). As far as the patient knew there was no other cleft lip or cleft palate in the family. The lip was closed in infancy. The palate was closed at 18 years of age; however, previous unsuccessful attempts at closure had been made in early childhood. Speech defect was typical but not as marked as one would expect with such a severe deformity. The good quality of speech was due, I am sure, to her determination and the fact that she had taken speech correction at Florida State University and the University of Michigan. There was severe underdevelopment of the anterior segment of the maxillary arch and tight upper lip due to the presence of scar tissue, giving the typical dish-faced appearance. Caries was very mild. We had no knowledge of the occlusion of either parent and, as she was an only child, no sibling comparison could be made. July
Read before 29, 30, 31,
the Southern Society and Aug. 1, 1951.
of
Orthodontists, 285
White
Sulphur
Springs,
W.
Va.,
286
HERBERT
D.
JAYNES
Etiology.-The etiology was unknown. Possibly heredity played some part; as previously stated, the mother had cleft of the lip on the same side as the patient. Micrognathia, V-shaped maxillary arch, and linguoversion of masillary teeth due t,o muscle pressure colla.psing the arch into the cleft were present. A.
GENERAL
PLAS
Plan of Treatment.-The first step in planning treatment procedure was a Kesling setup to appraise the possibilit,y of the case and to determine what teeth could be utilized and what teeth would have to be removed to accomplish the best results. Study of the setup suggested the following procedures: I. Rotation of the entire left maxillary buccal segment l~uccally, just as one would open a gate. 11. Labial tnovement of maxillary anterior teeth on the right side. 111. Reduction of tooth st,ructure in t,he mandibular arch to assist in harThe removal of the two mandibulal monizing the size of the two arches. first premolars would have been the procedure of choice, but due to the distoaxial inclination of the canines, this procedure was decided against and the left central incisor was removed instead. IV. Removal of the root of the left maxillary central incisor. V. Removal of the left, maxillary second molar. This tooth was in cornplete buccoversion and the position of the anerupted third molar was such that it would have prevented the ling’ual movement of the second molar. Since the third molar was in good position an(l had a well-formed crown, it was decided the procedure of choice would be removing the second molar and allowing the third molar to erupt. VI. Insertion of retaining plat,e, replacing maxillary left central and lateral incisors as well as the lost tissue in the cleft. B. APPLIANCES
USED
The maxillary appliances consisted of plain labial arch and a lingual extension on the side of the cleft. In the later stage of treatment, edgewise bands were used on anterior teeth in conjunction with 0.020 ant,erior segment in the labial arch. Mandibular appliance consisted of lingual arch and twin arch. class 111 elastics were also employed. C. SUPPLEMENTAL
No supplemental sician was used.
therapy
THERAPY
other than that prescribed
by the family
phy-
Progress of Case.-Since this was an out-of-state patient, appointments were kept to a minimum. After the preliminary work was completed she was seen at four-week intervals for approximately twenty-four months, for active treatment to establish the tooth arrangement worked out in the Kesling setup. This young lady gave full cooperation and there were no complications of any kind.
CLEFT
287
PALATE
A. Fig.
1.--A,
Taken
B. March
27,
1948:
B,
taken
Dec.
16.
1950.
Secondary I’reatment.-After primary treatment a maxillary plate was inserted carrying left eenkal and lateral incisors and filling in the cleft on the labial surface under the left nostril. Results Achieved.-There was great improvement in the appearance of the denture as well as facial balance. A much better functional relationship was established and it appeared the result was to be considered satisfactory. The patient was happier, more self-confident of her place in society, and had acquired a nice position. Observations and Conclusions.-It has been our experience in orthodontic treatment of patients with cleft palate that the Kesling setup is invaluable in arriving at a plan of treatment. It appears that the buccal segment on the side of the cleft is rotated buccally much as one would open a gate, widening the cleft in the hard palate. This does not disturb the soft tissue closure and seems to be a safe procedure. Post-treatment Findings.-Record photographs and casts, as well as posttreatment radiographs, were made. No evidence of periodontal disturbance or root resorption was noted in post-treatment radiographs, Surgery on t,he lip to smooth out mucous surface on the undersurface of the upper lip, and raise left ala of the nose, was advised. The patient wanted surgery done on the lip at the time she presented for treatment but we thought it wise to defer this until after orthodontic treatment. After treatment, the new arrangement of the maxillary teeth gives the plastic surgeon something t,o mold the lip over. Teeth were firm and stable in their new position. Soft tissue was normal. Speech defect had improved.
D. JAYNES,
PALATE OF
A
CASE
D.D.S., ATLANTA,
GA.
T
HE patient, C. B., was a white girl, 21 years of age, March, 1948. DiagnosB.-The patient presented Class I (Angle) malocclusion, a direct result of complete cleft of both hard and soft palates and lip on the left side, both palates and lip having been successfully closed by surgery. The mandible could be considered of normal size, development, and position. Intraoral radiographs revealed all teeth present in the mandibular arch with both third molars mesioangular impactions ; left maxillary first premolar and lateral incisor and right canine were congenitally missing. Only root of left maxillary central incisor remained in the cleft. Intraoral radiographs also revealed acceptable calcification of teeth and supporting alveolar bone, and absence of periodontal and periapical disturbance. This case exemplified the most typical cleft palate maxillary arch form and tooth malpositions, that is, the arch was V-shaped with apex forward; maxillary left -canine and first premolar and right central and lateral incisors were in complete linguoversion. The maxillary left second molar was in complete buccoversion. History and General Clinical Picture.-General physical development was good. There was no history of general illness throughout life other than mild childhood diseases : measles at 7 years, whooping cough at 10 years; otherShe had cod-liver oil and plenty wise she had always enjoyed good health. of fresh orange juice as a child. She always had milk in sufficient quantit,y. Mental health was good and she had ambitions and outlook of a normal 21year-old girl. Mother had normal palate but cleft of lip on the same side as the patient (left). As far as the patient knew there was no other cleft lip or cleft palate in the family. The lip was closed in infancy. The palate was closed at 18 years of age; however, previous unsuccessful attempts at closure had been made in early childhood. Speech defect was typical but not as marked as one would expect with such a severe deformity. The good quality of speech was due, I am sure, to her determination and the fact that she had taken speech correction at Florida State University and the University of Michigan. There was severe underdevelopment of the anterior segment of the maxillary arch and tight upper lip due to the presence of scar tissue, giving the typical dish-faced appearance. Caries was very mild. We had no knowledge of the occlusion of either parent and, as she was an only child, no sibling comparison could be made. July
Read before 29, 30, 31,
the Southern Society and Aug. 1, 1951.
of
Orthodontists, 285
White
Sulphur
Springs,
W.
Va.,
286
HERBERT
D.
JAYNES
Etiology.-The etiology was unknown. Possibly heredity played some part; as previously stated, the mother had cleft of the lip on the same side as the patient. Micrognathia, V-shaped maxillary arch, and linguoversion of masillary teeth due t,o muscle pressure colla.psing the arch into the cleft were present. A.
GENERAL
PLAS
Plan of Treatment.-The first step in planning treatment procedure was a Kesling setup to appraise the possibilit,y of the case and to determine what teeth could be utilized and what teeth would have to be removed to accomplish the best results. Study of the setup suggested the following procedures: I. Rotation of the entire left maxillary buccal segment l~uccally, just as one would open a gate. 11. Labial tnovement of maxillary anterior teeth on the right side. 111. Reduction of tooth st,ructure in t,he mandibular arch to assist in harThe removal of the two mandibulal monizing the size of the two arches. first premolars would have been the procedure of choice, but due to the distoaxial inclination of the canines, this procedure was decided against and the left central incisor was removed instead. IV. Removal of the root of the left maxillary central incisor. V. Removal of the left, maxillary second molar. This tooth was in cornplete buccoversion and the position of the anerupted third molar was such that it would have prevented the ling’ual movement of the second molar. Since the third molar was in good position an(l had a well-formed crown, it was decided the procedure of choice would be removing the second molar and allowing the third molar to erupt. VI. Insertion of retaining plat,e, replacing maxillary left central and lateral incisors as well as the lost tissue in the cleft. B. APPLIANCES
USED
The maxillary appliances consisted of plain labial arch and a lingual extension on the side of the cleft. In the later stage of treatment, edgewise bands were used on anterior teeth in conjunction with 0.020 ant,erior segment in the labial arch. Mandibular appliance consisted of lingual arch and twin arch. class 111 elastics were also employed. C. SUPPLEMENTAL
No supplemental sician was used.
therapy
THERAPY
other than that prescribed
by the family
phy-
Progress of Case.-Since this was an out-of-state patient, appointments were kept to a minimum. After the preliminary work was completed she was seen at four-week intervals for approximately twenty-four months, for active treatment to establish the tooth arrangement worked out in the Kesling setup. This young lady gave full cooperation and there were no complications of any kind.
CLEFT
287
PALATE
A. Fig.
1.--A,
Taken
B. March
27,
1948:
B,
taken
Dec.
16.
1950.
Secondary I’reatment.-After primary treatment a maxillary plate was inserted carrying left eenkal and lateral incisors and filling in the cleft on the labial surface under the left nostril. Results Achieved.-There was great improvement in the appearance of the denture as well as facial balance. A much better functional relationship was established and it appeared the result was to be considered satisfactory. The patient was happier, more self-confident of her place in society, and had acquired a nice position. Observations and Conclusions.-It has been our experience in orthodontic treatment of patients with cleft palate that the Kesling setup is invaluable in arriving at a plan of treatment. It appears that the buccal segment on the side of the cleft is rotated buccally much as one would open a gate, widening the cleft in the hard palate. This does not disturb the soft tissue closure and seems to be a safe procedure. Post-treatment Findings.-Record photographs and casts, as well as posttreatment radiographs, were made. No evidence of periodontal disturbance or root resorption was noted in post-treatment radiographs, Surgery on t,he lip to smooth out mucous surface on the undersurface of the upper lip, and raise left ala of the nose, was advised. The patient wanted surgery done on the lip at the time she presented for treatment but we thought it wise to defer this until after orthodontic treatment. After treatment, the new arrangement of the maxillary teeth gives the plastic surgeon something t,o mold the lip over. Teeth were firm and stable in their new position. Soft tissue was normal. Speech defect had improved.