CASE REPORTS
Improving the facial profile of a girl born with a right unilateral cleft lip and palate Lisa Lai-ying So, BDS, MDS* Pokfulam, Hong Kong HISTORY AND DIAGNOSIS The patient was born on Jan. 26, 1977, with a complete right unilateral cleft of the lip, alveolar process, and palate after a nomaal full-tcrm pregnancy and delivcry. The lip and *Lecturer, Department of Children's Dentistry and Orthodontics, Faculty of Dentistry, Universityof Ilong Kong.
811128556
alveolus ,,,,'ere repaired at the age of 3 months, whereas the hard and soft palates were primarily repaired at I IA years of age. On her first dental examination in June 1983, nmltiple carious deciduous teeth were found (Fig. 1). Subsequently, all deciduous molars were extracted under general anesthesia. Meticulous oral hygiene and prevcntive regimes were instrumented.
Fig. 1. Panoramic radiograph at age 6 years 5 months.
Fig. 2, Pretreatment facial photographs at age 12 years.
76
Volume 102 l~'ttlttb('r
Case reporls
77
I
Fig. 3. Panoramic radiograph at age 12 years.
. . . . . . .
.?.
m
j
9~
9
-.
i r''
Fig. 4. Pretreatment intraoral photographs.
As the patient grew, "the retrusive maxilla and nose'" became apparent, as stated in the examination notes on Oct. 2, 1984. She was eventually referred for orthodontic evaluation in January 1989 (Fig. 2). She had a permanent stage of dental development except the retained maxillary right
deciduous canine, while its permanent successor was unerupted and the maxillary right lateral incisor was missing (Fig. 3). The occlusal development demonstrated a Class II1 malt4cclusion. The maxillary arch ,,,,'as severely crowded with both second premolars being palatally displaced. A median dia-
78
C a s e reports
Am. J. Orthod. Dent~#w. Orthop. July 1992
Fig. 6. Frontal view of modified Hawley retainer, temporarily replacing maxillary left lateral incisor.
Fig. 5. Pretreatment lateral cephalometric radiograph.
sterna was evident, with the distal tilting of the maxillary right central incisor. The maxillary left canine was displaced slightly buccally. Mild crowding was evident in the mandibular arch, with mesiolabial rotation of the mandibular right canine and impaction of the mandibular left second premolar. The curve of Spee was markedly exaggerated. Molar relationships were Class I bilaterally. A lingual crossbite extended from the maxillary right first premolar to the maxillary left lateral incisor. Overjet was - 8 mm while overbite was excessive and reversed with half of the maxillary incisor crowns covered. The mandibular midline was shifted 2 mm to the left of the midfacial line. Neither an abnomml labial frenum nor a mandibular functional displacement was noted (Fig. 4). The lateral cephalometric analysis showed a rctrognathic maxilla and mandible in relation to the sella-nasion line. The corrected ANB angle was - 3 ~ The maxillary-mandibular plane angle was reduced to 14". The maxillary incisor was ',,,'ell situated with reference to the maxillary plane, while the mandibular incisor was slightly retroclined. The interincisal angle was increased to 130~, while the mandibular incisor was anterior to the A-Pogonion line. The lower facial height proportion was mildly reduced to 52.3% (Fig. 5). TREATMENT PLAN The treatment goals were to (I) relieve crowding and align teeth in both arches, (2) correct the crossbite, (3) create space for the maxillary right canine eruption,
and (4) position the maxillary teeth adjacent to the cleft so as to fabricate a prosthesis to replace the maxillary right lateral incisor. Both the patient and her mother strongly objected to any surgical procedures, such as alveolar bone grafting of the cleft or orthognathic surgery. The treatment goal in correcting the crossbite had to be modified by dental compensations, that is, proclining maxillary incisors and retroclining mandibular incisors. TREATMENT PROCEDURES Because of the arch length deficiency, it would be preferable to extract maxillary second premolars to minimize adverse palatal movement of the incisors and extract mandibular first premolars to maximize lingual movement of the mandibular incisors to achieve the maximal dental compensation in correcting this severe skeletal discrepancy. However, the carious mandibular right second premolar presented the problem, which led to a different choice of extraction. Therefore the retained maxillary deciduous canine, maxillary second premolars, mandibular left first premolar, and mandibular right second premolar were extracted. An edgewise appliance was placed on both maxillary and mandibular arches for alignment of teeth and correction of the exaggerated curve of Spee. Bite opening was accomplished by incorporating a marked reverse curve of Spee in the mandibular arch wire. The maxillary incisors were intentionally tipped labially despite a deficient skeletal apical base. Neither an extraoral appliance nor a biteplate was used. Crossbite correction and extraction space closure were achieved by continuous wear of Class III intermaxillary elastics,
Case reports 79
Volume 102 Ntonber 1
Fig. 7. Posttreatment facial photographs at age 13 years.
Fig. 8. Panoramic radiograph at retention phase.
which provided 2 ounces of force bilaterally. This helped the mesial movement of the maxillary first permanent molars, labial tipping of maxillary incisors, and retroclination of the mandibular anterior segment" to correct the crossbite and close extraction sites, lntramaxillary elastics were only applied to the mandibular labial segment in the form of powerchains. The appliances were removed after 12 months of active treatment. A modified Hawley retainer was placed in the mandible, while a maxillary Hawley retainer incorporating an acrylic tooth to replace the maxillary right lateral incisor was used on a full-time basis (Fig. 6 ) .
DISCUSSION
Most of the treatment goals were accomplished. Improvement in both the facial profile and the dental arch relationship was noted. A mild residual open bite was still present in the cleft area because of the inherent alveolar bony defect. Further uprighting or extrusion of the maxillary right canine was not permissible. The minor deviation in the resultant dental midlines was probably due to the pretreatment deviation of the mandibular dental midline; enhanced by the extraction of the carious mandibular right second premolar instead of the first premolar. Esthetic recountouring by corn-
80
Case reports
Am. J. Orthod.Dcntr
"
'
It"
Orthop. July 1992
!
Fig. 9. Posltreatment intraoral photographs.
Table I. Lateral c e p h a l o m e t r i c a n a l y s e s as c o m p a r e d w i t h S o u t h e r n C h i n e s e f e m a l e c e p h a l o m e t r i c normal values
I SNA SNB ANB cANB
UIMx LIMn MxMn UILI LIAPg Lower facial height percentage
Before treatment (9114188) 73 ~ 79~ - 6~ --30 117~ 109~ 14.~ 130~ 10 mm 52.3%
posite r e s t o r a t i o n w o u l d be beneficial for the m a x i l l a r y right c a n i n e . A p e r m a n e n t p r o s t h e s i s s u c h as a M a r y land b r i d g e or d e n t u r e is u l t i m a t e l y p l a n n e d to replace the m a x i l l a r y right lateral i n c i s o r ( F i g s . 7, 8, and 9 ) ' i n the future, p r e f e r a b l y after the r e t e n t i o n phase.
I
After treatment (4120190) 75 ~ 79 ~ - 4~ - 1.7~ 128~ 86 ~ 15~ 131~ 3 mm 52.5%
Normal vahtesfor Chinesefemales mean (• SD) 83.3 ~ (-,- 3.00) 80.2 ~ (_+ 3_2~ 3 . 2 ~ ( -- 2.4 ~ 117.7 ~ ( _ 6.5 ~) 98.5 ~ (-- 7.0 ~ 26.1 ~ ( _ 5.4 ~) 117.6~ -- 8 . 8 ~ ) 4.9 mm (-- 2.1 mm) 54.4% (-- 1.9"A)
There have been both maxillary and mandibular dental c o m p e n s a t i o n s . T h e m a x i l l a r y p l a n e has c h a n g e d in a d o w n w a r d a n d f o r w a r d d i r e c t i o n , w h i c h m i g h t b e d u e to the e f f e c t o f the C l a s s III i n t e r m a x i l l a r y elastics. T h e d o w n w a r d a n d b a c k w a r d g r o w t h o f the m a n d i b l e
I.'olunre 102
Cf/SI:" rr
81
Number I
r
)
Fig. 10. Posttreatment lateral cephalometric radiograph.
was most dramatic and contributed to the successful bite opening (Figs. 10 and 11, A through C, Table I). These compromises may not normally be acceptable for many orthodontists. However, in a case like this when surgery is definitely unacceptable, these modalities produce the achievable optimum, restoring normal flmction and esthetics. A longer period of retention and observation is necessary to check the stability of the resulting occlusion. REFERENCE I. Cooke MS. Cephalometrie analysis base on natural head posture of Chinese children in Hong Kong. [Dissertation] University of ilong Kong, 1986;227-31. Reprint requests to:
Dr. Lisa So Department of Children's Dentistry and Orthodontics Prince Philip Dental Hospital 34 Hospital Rd. Hong Kong
Fig. 11. A, Superimposition. on cranial base of tracings obtained before treatment ( ) and at retention ( . . . . ). B, Superimposition on maxillary plane of tracings obtained before treatment ( ) and at retention ( . . . . ) C, Superimposition on mandibular symphysis of tracings obtained before treatment ( ) and at retention ( . . . . ).
Improving the facial profile of a girl born with a right unilateral cleft lip and palate Lisa Lai-ying So, BDS, MDS* Pokfulam, Hong Kong HISTORY AND DIAGNOSIS The patient was born on Jan. 26, 1977, with a complete right unilateral cleft of the lip, alveolar process, and palate after a nomaal full-tcrm pregnancy and delivcry. The lip and *Lecturer, Department of Children's Dentistry and Orthodontics, Faculty of Dentistry, Universityof Ilong Kong.
811128556
alveolus ,,,,'ere repaired at the age of 3 months, whereas the hard and soft palates were primarily repaired at I IA years of age. On her first dental examination in June 1983, nmltiple carious deciduous teeth were found (Fig. 1). Subsequently, all deciduous molars were extracted under general anesthesia. Meticulous oral hygiene and prevcntive regimes were instrumented.
Fig. 1. Panoramic radiograph at age 6 years 5 months.
Fig. 2, Pretreatment facial photographs at age 12 years.
76
Volume 102 l~'ttlttb('r
Case reporls
77
I
Fig. 3. Panoramic radiograph at age 12 years.
. . . . . . .
.?.
m
j
9~
9
-.
i r''
Fig. 4. Pretreatment intraoral photographs.
As the patient grew, "the retrusive maxilla and nose'" became apparent, as stated in the examination notes on Oct. 2, 1984. She was eventually referred for orthodontic evaluation in January 1989 (Fig. 2). She had a permanent stage of dental development except the retained maxillary right
deciduous canine, while its permanent successor was unerupted and the maxillary right lateral incisor was missing (Fig. 3). The occlusal development demonstrated a Class II1 malt4cclusion. The maxillary arch ,,,,'as severely crowded with both second premolars being palatally displaced. A median dia-
78
C a s e reports
Am. J. Orthod. Dent~#w. Orthop. July 1992
Fig. 6. Frontal view of modified Hawley retainer, temporarily replacing maxillary left lateral incisor.
Fig. 5. Pretreatment lateral cephalometric radiograph.
sterna was evident, with the distal tilting of the maxillary right central incisor. The maxillary left canine was displaced slightly buccally. Mild crowding was evident in the mandibular arch, with mesiolabial rotation of the mandibular right canine and impaction of the mandibular left second premolar. The curve of Spee was markedly exaggerated. Molar relationships were Class I bilaterally. A lingual crossbite extended from the maxillary right first premolar to the maxillary left lateral incisor. Overjet was - 8 mm while overbite was excessive and reversed with half of the maxillary incisor crowns covered. The mandibular midline was shifted 2 mm to the left of the midfacial line. Neither an abnomml labial frenum nor a mandibular functional displacement was noted (Fig. 4). The lateral cephalometric analysis showed a rctrognathic maxilla and mandible in relation to the sella-nasion line. The corrected ANB angle was - 3 ~ The maxillary-mandibular plane angle was reduced to 14". The maxillary incisor was ',,,'ell situated with reference to the maxillary plane, while the mandibular incisor was slightly retroclined. The interincisal angle was increased to 130~, while the mandibular incisor was anterior to the A-Pogonion line. The lower facial height proportion was mildly reduced to 52.3% (Fig. 5). TREATMENT PLAN The treatment goals were to (I) relieve crowding and align teeth in both arches, (2) correct the crossbite, (3) create space for the maxillary right canine eruption,
and (4) position the maxillary teeth adjacent to the cleft so as to fabricate a prosthesis to replace the maxillary right lateral incisor. Both the patient and her mother strongly objected to any surgical procedures, such as alveolar bone grafting of the cleft or orthognathic surgery. The treatment goal in correcting the crossbite had to be modified by dental compensations, that is, proclining maxillary incisors and retroclining mandibular incisors. TREATMENT PROCEDURES Because of the arch length deficiency, it would be preferable to extract maxillary second premolars to minimize adverse palatal movement of the incisors and extract mandibular first premolars to maximize lingual movement of the mandibular incisors to achieve the maximal dental compensation in correcting this severe skeletal discrepancy. However, the carious mandibular right second premolar presented the problem, which led to a different choice of extraction. Therefore the retained maxillary deciduous canine, maxillary second premolars, mandibular left first premolar, and mandibular right second premolar were extracted. An edgewise appliance was placed on both maxillary and mandibular arches for alignment of teeth and correction of the exaggerated curve of Spee. Bite opening was accomplished by incorporating a marked reverse curve of Spee in the mandibular arch wire. The maxillary incisors were intentionally tipped labially despite a deficient skeletal apical base. Neither an extraoral appliance nor a biteplate was used. Crossbite correction and extraction space closure were achieved by continuous wear of Class III intermaxillary elastics,
Case reports 79
Volume 102 Ntonber 1
Fig. 7. Posttreatment facial photographs at age 13 years.
Fig. 8. Panoramic radiograph at retention phase.
which provided 2 ounces of force bilaterally. This helped the mesial movement of the maxillary first permanent molars, labial tipping of maxillary incisors, and retroclination of the mandibular anterior segment" to correct the crossbite and close extraction sites, lntramaxillary elastics were only applied to the mandibular labial segment in the form of powerchains. The appliances were removed after 12 months of active treatment. A modified Hawley retainer was placed in the mandible, while a maxillary Hawley retainer incorporating an acrylic tooth to replace the maxillary right lateral incisor was used on a full-time basis (Fig. 6 ) .
DISCUSSION
Most of the treatment goals were accomplished. Improvement in both the facial profile and the dental arch relationship was noted. A mild residual open bite was still present in the cleft area because of the inherent alveolar bony defect. Further uprighting or extrusion of the maxillary right canine was not permissible. The minor deviation in the resultant dental midlines was probably due to the pretreatment deviation of the mandibular dental midline; enhanced by the extraction of the carious mandibular right second premolar instead of the first premolar. Esthetic recountouring by corn-
80
Case reports
Am. J. Orthod.Dcntr
"
'
It"
Orthop. July 1992
!
Fig. 9. Posltreatment intraoral photographs.
Table I. Lateral c e p h a l o m e t r i c a n a l y s e s as c o m p a r e d w i t h S o u t h e r n C h i n e s e f e m a l e c e p h a l o m e t r i c normal values
I SNA SNB ANB cANB
UIMx LIMn MxMn UILI LIAPg Lower facial height percentage
Before treatment (9114188) 73 ~ 79~ - 6~ --30 117~ 109~ 14.~ 130~ 10 mm 52.3%
posite r e s t o r a t i o n w o u l d be beneficial for the m a x i l l a r y right c a n i n e . A p e r m a n e n t p r o s t h e s i s s u c h as a M a r y land b r i d g e or d e n t u r e is u l t i m a t e l y p l a n n e d to replace the m a x i l l a r y right lateral i n c i s o r ( F i g s . 7, 8, and 9 ) ' i n the future, p r e f e r a b l y after the r e t e n t i o n phase.
I
After treatment (4120190) 75 ~ 79 ~ - 4~ - 1.7~ 128~ 86 ~ 15~ 131~ 3 mm 52.5%
Normal vahtesfor Chinesefemales mean (• SD) 83.3 ~ (-,- 3.00) 80.2 ~ (_+ 3_2~ 3 . 2 ~ ( -- 2.4 ~ 117.7 ~ ( _ 6.5 ~) 98.5 ~ (-- 7.0 ~ 26.1 ~ ( _ 5.4 ~) 117.6~ -- 8 . 8 ~ ) 4.9 mm (-- 2.1 mm) 54.4% (-- 1.9"A)
There have been both maxillary and mandibular dental c o m p e n s a t i o n s . T h e m a x i l l a r y p l a n e has c h a n g e d in a d o w n w a r d a n d f o r w a r d d i r e c t i o n , w h i c h m i g h t b e d u e to the e f f e c t o f the C l a s s III i n t e r m a x i l l a r y elastics. T h e d o w n w a r d a n d b a c k w a r d g r o w t h o f the m a n d i b l e
I.'olunre 102
Cf/SI:" rr
81
Number I
r
)
Fig. 10. Posttreatment lateral cephalometric radiograph.
was most dramatic and contributed to the successful bite opening (Figs. 10 and 11, A through C, Table I). These compromises may not normally be acceptable for many orthodontists. However, in a case like this when surgery is definitely unacceptable, these modalities produce the achievable optimum, restoring normal flmction and esthetics. A longer period of retention and observation is necessary to check the stability of the resulting occlusion. REFERENCE I. Cooke MS. Cephalometrie analysis base on natural head posture of Chinese children in Hong Kong. [Dissertation] University of ilong Kong, 1986;227-31. Reprint requests to:
Dr. Lisa So Department of Children's Dentistry and Orthodontics Prince Philip Dental Hospital 34 Hospital Rd. Hong Kong
Fig. 11. A, Superimposition. on cranial base of tracings obtained before treatment ( ) and at retention ( . . . . ). B, Superimposition on maxillary plane of tracings obtained before treatment ( ) and at retention ( . . . . ) C, Superimposition on mandibular symphysis of tracings obtained before treatment ( ) and at retention ( . . . . ).
