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Treatment of bilateral cleft lip and palate
American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS Fotmded in 1915
Volume 100 Number 4
October 1991
Copyright © 1991 by the American Association of Orthodontists
CASE REPORTS
Treatment of bilateral cleft lip and palate Khalid Balkhi, BDS, Susan Fadanelli, DMD, and d. Daniel Subtelny, DDS, MS Rochester, N.Y.
I n 1968 the incidence of cleft lip and palate was approximately 1 per 500 live births. ~ Owens et al. 2 in 1985 reported an incidence rate of 1.40 per 1000 live 814111653
births and stillbirths. In a 1987 review by Vanderas, 3 it was reported that the incidence rate of cleft lip and palate in the United States was 0.36 to 0.83 per 1000 live births. Cleft lip and cleft palate are congenital craniofacial
bw-"
Fig. 1. Pretreatment facial photographs in 1976, age 6 years 4 months.
Fig. 2. Pretreatment intraoral photograph.
297
298
Balkhi, Fadanelli, ,~
~
. r.Cute'tn"
Am. J. Orthod. Dentofac. Orthop. October 1991
Fig. 3. Pretreatment study models.
malformations that can have a myriad of etiologic factors as well as complications. The treatment procedure for these patients presents a challenge to the entire team of health care professionals involved. 4-6 It is an especially unique challenge to the clinical orthodontist, as a flexible treatment plan and continuous evaluation are required for the changing needs and problems as the
patient matures. The treatment of these patients may also be viewed as a unique opportunity to help mold a child's character, as the " . . . behavior of other people during the formative years in the life of a cleft lip and palate child will frequently build up within him lasting individual attitudes and expectations. ''7 The following is a report of such a case.
Vohone I00 Number 4
Case report
NA-Fff
299
9
[SNA 8 [NPo9-FH [SNB J
T.W.1976
B Fig. 4. Pretreatment cephalometric tracings showing lateral (A) and frontal (B) views.
Fig. 5. Lateral (A) and frontal (B) cephalometric tracings after completion of first phase of treatment.
PATIENT HISTORY, CLINICAL EXAM, AND DIAGNOSIS The patient was referred to the Eastman Dental Center in September 1976, at the age of 6 years 3 months. He was born with bilateral cleft lip and palate; both clefts were surgically
repaired at an early age. A pharyngeal flap procedure had also been performed. On initial examination, the patient demonstrated a retrognathic convex soft tissue profile, with a flattening of both alar cartilages, an inverted upper lip outline, an everted
300
Balkhi, Fadanelli, Subtelny
A,,. J. Orthod. Dentofac. Orthop. October 1991
Fig. 6. Posttreatment retention models showing morphology of peg-shaped lateral incisors and malformed right central incisor.
lower lip, and a pronounced mentalis hyperactivity on lip closure (Fig. 1). Intraorally, the premaxilla contained only the right deciduous lateral incisor (Fig. 2). Dentally, a Class I molar relationship was evident. Arch length discrepancies were present in both arches. The maxillary buccal segments were collapsed anteriorly, with the
deciduous canines and first deciduous molars within the buccal segment. The lower dental arch had a square arch form with moderate crowding and rotations in the deciduous incisor area (Fig. 3). Cephalometrically, the maxilla was slightly protrusive in relation to the forehead but constricted in the transverse dimension. The mandible was slightly retrognathic and showed
Vohune 1(30 Nzlmber 4
Case report
;='
Fig. 7. Retention facial photographs in 1987.
Fig. 8. Retention intraoral photographs in 1987, showing porcelain veneer crowns on maxillary incisors, and noncarious dark stain around upper first molar.
301
302
Balkhi, Fadanelli,
O U ULrC ' u'LIeI""'
Am. J. Orthod. Dentofac. Orthop. October 1991
Fig. 8. Cont'd.
/ NA-FH 87* SNA 79 NP~-FH ~3 T.W.19~ ~
SNB
76
~._-"
\\ II J/
A
Fig. 9. Retention cephalometric tracings showing lateral (A) and frontal (B) views.
signs of a vertical growth pattern. The patient also had oral respiration. The denture bases were well related to their respective jaws. The maxillary and mandibular incisors were severely retroclined to the palatal and mandibular planes, respectively. The mandibular left third molar was congenitally missing (Fig. 4).
TREATMENT The primary treatment objectives were to reestablish the correct maxillary arch form, create as much arch length as possible, guide the eruption of the permanent dentition by selective extraction of deciduous teeth, and encourage man-
dibular growth in a predominantly vertical fashion (to avoid a proganthic appearance in the future). Treatment was initiated by placing an Arnold expander banded to the right and left deciduous second molars to expand the collapsed maxillary buccal segments, with greater anterior expansion occurring to restore the maxillary arch and to correct its form. When the permanent maxillary incisors erupted, a standard edgewise appliance was placed. Increased expansion with buccal root torque to the posterior teeth was incorporated into the maxillary arch wire. During this time, the upper central incisors were rotated and subsequently advanced, maintaining labial root torque. Progressive lower
Volume tO0
Case report
303
Number 4
°. . . . . . °.-,
T.W. .....
-
1976
1988 "\..
"'--..
Fig. 10. Superimpositions of initial and retention lateral cephalometric tracings, showing favorable growth pattern.
Fig. 11. Facial photographs in 1988 (1 year 2 months in retention).
bonding of appliances was done. The crowns of the lower incisors were positioned forward, providing a more normal lower incisor inclination. To ensure that the lower first molars would not extrude, a lower lingual holding arch was cemented. This also served to maintain the mandibular arch length. After achieving expansion of the upper first molars, an Indiana holding arch (transpalatal bar) was placed on the
molars to maintain the arch width, and a removable acrylic palatal plate was inserted, allowing for the maintenance of the skeletal and dental expansions, enhancing esthetics, and improving speech by fistula closure. A reevaluation of the case was performed 3 years after the commencement of orthodontic treatment, as the initial objectives of treatment had been completed. It was decided
304
Balkhi, Fadanelli, Subtelnv "
Am. J. Orthod. Dentofac. Orthop. October 1991
l~...i
---., ~ . . . .
~
Fig. 12. Intraoral photographs in 1988 (1 year 2 months in retention), showing no dental relapse. Also, the maxillary modified Hawley retainer and the lower lingual fixed Zachrisson appliance from canine to canine could be seen. A, Frontal view with maxillary modified Hawley. B, Right buccal view. C, Frontal view, unobstructive. D, Left buccal view. E, Maxillary occlusal view. F, Mandibular occlusal view.
that face mask (reverse headgear) therapy would not be instituted, as the lateral cephalometric tracing revealed wellrelated maxillary and mandibular denture bases, with a favorable vertical mandibular growth tendency (Fig. 5).
In 1982 bone grafts were performed to aid in the eruption of the maxillary canines, as well as to stabilize arch length, width, and symmetry. Nose and lip revisions were performed over the next 2 years.
Votume tO0 Number 4
In 1984 the mandibular arch was placed in retention with a G wire fixed to the mandibular first molars. At this time, the second maxillary molars had erupted, and the Indiana holding arch was now placed on them to allow further expansion and rotation of the first molars by arch wire mechanics. Two years later the maxillary appliances were removed, and the arch was retained with a Hawley appliance. The mandibular G wire Was removed and replaced with a fixed bonded Zachrisson retainer from canine to canine iFig. 6). In 1987 all four maxillary incisors were prosthetically restored with porcelain veneer crowns to improve both lootb structure and axial inclination (Figs. 7 and 8). Superimposition of the tracings of the initial and retention lateral cephalograms, shows favorable downward and forward growth of the maxilla and the mandible. The posterior part of the palate was tipped down more than the anterior part, but this favored downward repositioning of the mandible (Figs. 9 and 10). The patient has continued postretention follow-up visits. The most recent visit was in November 1988. He continues to wear the prescribed retention appliances and demonstrates no apparent tendency for relapse (Figs. 11 and 12). We express our sincere gratitude to the orlbodonlic residents of the Eastman Dental Center who participated in the treatment of this case.
Case report
305
REFERENCES I. Fogh Anderson P. Increasing incidents of facial clefts Genetically or non-genetically determined. In: Longaere JJ', ed. Cmnlofacial anomalies pathogenesis and repair. Philadelphia: JB Lippincott, 1968:27-9. 2. Owens JR, Jones JW, ttarris F. Epidemiology of facial clefting. Arch Dis Child 1985;60:521-4. 3. Vanderas AP. Incidence of cleft lip, cleft palate, and cleft lip and palate among races: a review. Cleft Palate J 1987;24:216-25 (65 ref.). 4. Pruzansky S. Factors determining arch form in cleft lip and palate. AM J Onmort 1955;41:827-51. 5. Pruzansky S. 3he role of the orthodontist in a cleft palate team. Plast Rcconstr Surg 1954;14:10-29. 6. Subtelny JD. The importance of early orthodontic treatment in cleft palate planning. Angle Orthod 1957;27:148-58. 7. Subtelny JD. Orthodontic treatment of cleft lip and palate, birth to adulthood. Angle Orthod 1966;36:273-92. Reprbzt requexts to:
Dr. Bruce Goldin Eastman Dental Center 625 Elmwood Ave. Rochester, NY 14620
Volume 100 Number 4
October 1991
Copyright © 1991 by the American Association of Orthodontists
CASE REPORTS
Treatment of bilateral cleft lip and palate Khalid Balkhi, BDS, Susan Fadanelli, DMD, and d. Daniel Subtelny, DDS, MS Rochester, N.Y.
I n 1968 the incidence of cleft lip and palate was approximately 1 per 500 live births. ~ Owens et al. 2 in 1985 reported an incidence rate of 1.40 per 1000 live 814111653
births and stillbirths. In a 1987 review by Vanderas, 3 it was reported that the incidence rate of cleft lip and palate in the United States was 0.36 to 0.83 per 1000 live births. Cleft lip and cleft palate are congenital craniofacial
bw-"
Fig. 1. Pretreatment facial photographs in 1976, age 6 years 4 months.
Fig. 2. Pretreatment intraoral photograph.
297
298
Balkhi, Fadanelli, ,~
~
. r.Cute'tn"
Am. J. Orthod. Dentofac. Orthop. October 1991
Fig. 3. Pretreatment study models.
malformations that can have a myriad of etiologic factors as well as complications. The treatment procedure for these patients presents a challenge to the entire team of health care professionals involved. 4-6 It is an especially unique challenge to the clinical orthodontist, as a flexible treatment plan and continuous evaluation are required for the changing needs and problems as the
patient matures. The treatment of these patients may also be viewed as a unique opportunity to help mold a child's character, as the " . . . behavior of other people during the formative years in the life of a cleft lip and palate child will frequently build up within him lasting individual attitudes and expectations. ''7 The following is a report of such a case.
Vohone I00 Number 4
Case report
NA-Fff
299
9
[SNA 8 [NPo9-FH [SNB J
T.W.1976
B Fig. 4. Pretreatment cephalometric tracings showing lateral (A) and frontal (B) views.
Fig. 5. Lateral (A) and frontal (B) cephalometric tracings after completion of first phase of treatment.
PATIENT HISTORY, CLINICAL EXAM, AND DIAGNOSIS The patient was referred to the Eastman Dental Center in September 1976, at the age of 6 years 3 months. He was born with bilateral cleft lip and palate; both clefts were surgically
repaired at an early age. A pharyngeal flap procedure had also been performed. On initial examination, the patient demonstrated a retrognathic convex soft tissue profile, with a flattening of both alar cartilages, an inverted upper lip outline, an everted
300
Balkhi, Fadanelli, Subtelny
A,,. J. Orthod. Dentofac. Orthop. October 1991
Fig. 6. Posttreatment retention models showing morphology of peg-shaped lateral incisors and malformed right central incisor.
lower lip, and a pronounced mentalis hyperactivity on lip closure (Fig. 1). Intraorally, the premaxilla contained only the right deciduous lateral incisor (Fig. 2). Dentally, a Class I molar relationship was evident. Arch length discrepancies were present in both arches. The maxillary buccal segments were collapsed anteriorly, with the
deciduous canines and first deciduous molars within the buccal segment. The lower dental arch had a square arch form with moderate crowding and rotations in the deciduous incisor area (Fig. 3). Cephalometrically, the maxilla was slightly protrusive in relation to the forehead but constricted in the transverse dimension. The mandible was slightly retrognathic and showed
Vohune 1(30 Nzlmber 4
Case report
;='
Fig. 7. Retention facial photographs in 1987.
Fig. 8. Retention intraoral photographs in 1987, showing porcelain veneer crowns on maxillary incisors, and noncarious dark stain around upper first molar.
301
302
Balkhi, Fadanelli,
O U ULrC ' u'LIeI""'
Am. J. Orthod. Dentofac. Orthop. October 1991
Fig. 8. Cont'd.
/ NA-FH 87* SNA 79 NP~-FH ~3 T.W.19~ ~
SNB
76
~._-"
\\ II J/
A
Fig. 9. Retention cephalometric tracings showing lateral (A) and frontal (B) views.
signs of a vertical growth pattern. The patient also had oral respiration. The denture bases were well related to their respective jaws. The maxillary and mandibular incisors were severely retroclined to the palatal and mandibular planes, respectively. The mandibular left third molar was congenitally missing (Fig. 4).
TREATMENT The primary treatment objectives were to reestablish the correct maxillary arch form, create as much arch length as possible, guide the eruption of the permanent dentition by selective extraction of deciduous teeth, and encourage man-
dibular growth in a predominantly vertical fashion (to avoid a proganthic appearance in the future). Treatment was initiated by placing an Arnold expander banded to the right and left deciduous second molars to expand the collapsed maxillary buccal segments, with greater anterior expansion occurring to restore the maxillary arch and to correct its form. When the permanent maxillary incisors erupted, a standard edgewise appliance was placed. Increased expansion with buccal root torque to the posterior teeth was incorporated into the maxillary arch wire. During this time, the upper central incisors were rotated and subsequently advanced, maintaining labial root torque. Progressive lower
Volume tO0
Case report
303
Number 4
°. . . . . . °.-,
T.W. .....
-
1976
1988 "\..
"'--..
Fig. 10. Superimpositions of initial and retention lateral cephalometric tracings, showing favorable growth pattern.
Fig. 11. Facial photographs in 1988 (1 year 2 months in retention).
bonding of appliances was done. The crowns of the lower incisors were positioned forward, providing a more normal lower incisor inclination. To ensure that the lower first molars would not extrude, a lower lingual holding arch was cemented. This also served to maintain the mandibular arch length. After achieving expansion of the upper first molars, an Indiana holding arch (transpalatal bar) was placed on the
molars to maintain the arch width, and a removable acrylic palatal plate was inserted, allowing for the maintenance of the skeletal and dental expansions, enhancing esthetics, and improving speech by fistula closure. A reevaluation of the case was performed 3 years after the commencement of orthodontic treatment, as the initial objectives of treatment had been completed. It was decided
304
Balkhi, Fadanelli, Subtelnv "
Am. J. Orthod. Dentofac. Orthop. October 1991
l~...i
---., ~ . . . .
~
Fig. 12. Intraoral photographs in 1988 (1 year 2 months in retention), showing no dental relapse. Also, the maxillary modified Hawley retainer and the lower lingual fixed Zachrisson appliance from canine to canine could be seen. A, Frontal view with maxillary modified Hawley. B, Right buccal view. C, Frontal view, unobstructive. D, Left buccal view. E, Maxillary occlusal view. F, Mandibular occlusal view.
that face mask (reverse headgear) therapy would not be instituted, as the lateral cephalometric tracing revealed wellrelated maxillary and mandibular denture bases, with a favorable vertical mandibular growth tendency (Fig. 5).
In 1982 bone grafts were performed to aid in the eruption of the maxillary canines, as well as to stabilize arch length, width, and symmetry. Nose and lip revisions were performed over the next 2 years.
Votume tO0 Number 4
In 1984 the mandibular arch was placed in retention with a G wire fixed to the mandibular first molars. At this time, the second maxillary molars had erupted, and the Indiana holding arch was now placed on them to allow further expansion and rotation of the first molars by arch wire mechanics. Two years later the maxillary appliances were removed, and the arch was retained with a Hawley appliance. The mandibular G wire Was removed and replaced with a fixed bonded Zachrisson retainer from canine to canine iFig. 6). In 1987 all four maxillary incisors were prosthetically restored with porcelain veneer crowns to improve both lootb structure and axial inclination (Figs. 7 and 8). Superimposition of the tracings of the initial and retention lateral cephalograms, shows favorable downward and forward growth of the maxilla and the mandible. The posterior part of the palate was tipped down more than the anterior part, but this favored downward repositioning of the mandible (Figs. 9 and 10). The patient has continued postretention follow-up visits. The most recent visit was in November 1988. He continues to wear the prescribed retention appliances and demonstrates no apparent tendency for relapse (Figs. 11 and 12). We express our sincere gratitude to the orlbodonlic residents of the Eastman Dental Center who participated in the treatment of this case.
Case report
305
REFERENCES I. Fogh Anderson P. Increasing incidents of facial clefts Genetically or non-genetically determined. In: Longaere JJ', ed. Cmnlofacial anomalies pathogenesis and repair. Philadelphia: JB Lippincott, 1968:27-9. 2. Owens JR, Jones JW, ttarris F. Epidemiology of facial clefting. Arch Dis Child 1985;60:521-4. 3. Vanderas AP. Incidence of cleft lip, cleft palate, and cleft lip and palate among races: a review. Cleft Palate J 1987;24:216-25 (65 ref.). 4. Pruzansky S. Factors determining arch form in cleft lip and palate. AM J Onmort 1955;41:827-51. 5. Pruzansky S. 3he role of the orthodontist in a cleft palate team. Plast Rcconstr Surg 1954;14:10-29. 6. Subtelny JD. The importance of early orthodontic treatment in cleft palate planning. Angle Orthod 1957;27:148-58. 7. Subtelny JD. Orthodontic treatment of cleft lip and palate, birth to adulthood. Angle Orthod 1966;36:273-92. Reprbzt requexts to:
Dr. Bruce Goldin Eastman Dental Center 625 Elmwood Ave. Rochester, NY 14620