|Year : 2016 | Volume
| Issue : 2 | Page : 116-119
Orthodontic management of excessive incisor display of an adult bilateral cleft lip and palate patient
Om Prakash Kharbanda1, Ashish Prasad2, Rahul Minotra3, Shailendra Singh Rana4
1 Professor and Head, Division of Orthodontics and Dentofacial Deformities,Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
2 PG Student, Division of Orthodontics and Dentofacial Deformities,Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
3 Former PG Student, Division of Orthodontics and Dentofacial Deformities,Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
4 Senior Resident, Division of Orthodontics and Dentofacial Deformities,Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||8-Apr-2016|
Om Prakash Kharbanda
Division of Orthodontics and Dentofacial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
This report entails successful orthodontic treatment of a case of postsurgical malocclusion, short upper lip, and excessive incisor display in an adult patient with bilateral cleft lip and palate. The patient underwent cleft lip repair at an early age of 2 years followed by palatoplasty at the age of 6 years and alveoloplasty at an age of 26 years. He reported with irregular teeth, inability to close lips, excessive visibility of upper incisors associated with short upper lip and difficulty in speech. He was treated with maxillary arch expansion, arch alignment, and intrusion of the incisors followed by prosthetic replacement of the missing right and left lateral incisors. Subsequently, he underwent nose and lip revision surgery at the age of 32 years. The orthodontic procedures and prosthetic rehabilitation have resulted in a near normal dental occlusion with significant improvement in esthetics and psychosocial benefits to the individual. These benefits were further enhanced by nose and lip revision surgery.
Keywords: Bilateral cleft lip and palate, cleft lip and palate, incisor intrusion, orthodontic treatment
|How to cite this article:|
Kharbanda OP, Prasad A, Minotra R, Rana SS. Orthodontic management of excessive incisor display of an adult bilateral cleft lip and palate patient. J Indian Orthod Soc 2016;50:116-9
|How to cite this URL:|
Kharbanda OP, Prasad A, Minotra R, Rana SS. Orthodontic management of excessive incisor display of an adult bilateral cleft lip and palate patient. J Indian Orthod Soc [serial online] 2016 [cited 2019 May 25];50:116-9. Available from: http://www.jios.in/text.asp?2016/50/2/116/179945
| Introduction|| |
The bilateral cleft lip and palate (BCLP) deformity has a wide degree of variability in regards to the severity of the cleft (incomplete vs. complete) and most importantly, the premaxilla. The deformity is characterized by a protruding maxilla, prolabium lacking muscle fibers with a blunted white roll, vertically long lateral lip elements widely spaced due to discontinuity of the orbicularis oris, short columella, flattened nose, and abnormally positioned alar cartilages.
The cephalometric studies of BCLP showed that in complete bilateral clefts of the lip and alveolus with intact palates, the premaxilla was protrusive but palatal size was well within normal limits.
Adult patients with bilateral cleft lip and/or palate display malocclusion characterized by anterior deep bite, protruded maxilla and bilateral collapse of the buccal maxillary segments. The extrusion of upper incisors and/or short upper lip causes esthetic problems.
Facial esthetic is greatly influenced by the amount of incisor display at rest and during smile. Three quarters of upper incisors' crown height to 2 mm of gingival display is considered normal/ideal exposure during smile.
The static and dynamic smile is severely compromised in BCLP patients. The maxillary incisors should be moved toward alveolus in the vertical direction that improves their relationship to the resting lip position. In BCLP patients, a greater Morley's ratio is a significant problem as the lip shrinks due to surgical scarring.
Intrusion of maxillary incisors is a difficult tooth movement to perform in adult. Here, we report a successful treatment of a 27-year-old male patient with operated BCLP with excessive incisor display and collapsed maxilla.
| Case Report|| |
A 27-year-old male patient with operated BCLP with complaints of inability to close lips, irregular teeth, and difficulty in a speech reported for the improvement in his esthetic and function. The patient was the first child of nonconsanguineous marriage with nonrelevant history of cleft. The child was delivered at term, and pregnancy was normal [Figure 1].
|Figure 1: Pedigree chart, showing nonfamiliar, sporadic occurrence of bilateral cleft lip and palate|
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The patient underwent a bilateral cleft lip repair at an early age of 2 years followed by palatoplasty at the age of 6 years and alveoloplasty at an age of 26 years. The patient had a leptoprosopic face, an orthognathic profile and incompetent lips with an asymmetrical nose, and a bilateral scar extending from the vermilion border of lip to the base of nose with an excessive incisor display at rest and during smile [Figure 2].
|Figure 2: Pretreatment extraoral and intraoral photographs and radiographs showing collapsed upper arch and extrusion of upper incisors|
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Intraorally, the upper arch was collapsed and asymmetric with the scar of the repaired cleft palate and alveolus on the left side with a protruding premaxilla and posterior buccal crossbite. Maxillary right and left lateral incisors and mandibular right and left first permanent molars were missing. Due to missing right and left permanent mandibular, first molars, the second mandibular right and left permanent molars had drifted mesially to partially close the space. The mandibular left second permanent molar was root canal treated. The upper right and left third molars were partially erupted. There was an overjet of 8mm with an overbite of 6 mm [Figure 2].
Patient showed nasal twang of voice, oronasal breathing, and a typical swallowing pattern. The orthopantomogram showed missing upper right and left lateral incisors and missing lower right and left first permanent molars. Cephalometric analysis showed Class II skeletal base, mild convex profile, vertical growth pattern with proclined upper incisors.
The objectives, in this case, were to correct the constriction of upper arch and align the maxillary arch together with intrusion of maxillary incisors and final nose and lip revision surgery. After initial oral prophylaxis and restorative procedures were carried out, a fixed quad helix appliance soldered to the molar bands was cemented in place. Postexpansion and during initial alignment, a modified transpalatal arch with arms extending on the premolars was placed as a retentive appliance [Figure 3]. With regular activation, the upper arch was expanded in about 1½ years. Simultaneous retraction of upper right canine in 0.017” × 0.025” titanium molybdenum alloy (TMA) was initiated. Initial leveling and alignment was done using 0.016” NiTi wires and the archwires were sequentially changed to higher dimension. A 0.016” × 0.022” TMA Ricketts intrusion arch was ligated to intrude the maxillary central incisors. Mandibular permanent second molars were mesialized to close the space of missing first permanent molars (using T-loop mechanics). Mandibular permanent third molars also migrated mesially, and proper space closure was achieved. After debonding, a removable partial denture in relation to maxillary right and left lateral incisors was placed. In the mandibular arch, retention was provided with flexible spiral wire retainer [Figure 4]. Thereafter, the patient underwent a final nose and lip revision surgery at the age of 32 years [Figure 5]. The posttreatment orthopantomogram showed mesialization of second and third molar and space closure of missing lower first molars [Figure 5].
|Figure 3: Mid treatment intraoral photographs showing rigid rectangular wire in upper arch, modified transpalatal arch with extended anterior arm acting as a retainer and T-loop in lower arch for space closure|
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|Figure 4: Posttreatment (prenose and lip revision surgery) extraoral and intraoral photographs showing removable partial denture serving as a retainer and obturator plate|
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|Figure 5: Posttreatment extraoral and intraoral photographs and radiographs after 1-year follow-up|
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| Discussion|| |
Patients with cleft lip and palate often suffer from esthetic, morphological, and functional problems in the dentofacial region. A large number of patients suffer from poor self-esteem due to an unesthetic facial appearance.
Management of protruded premaxilla and excessive incisor display can be a confounding problem in adult BCLP cases. Many techniques have been proposed to deal with this problem, e.g., extraoral traction, premaxillary surgical setback, premaxillary excision, and incisor intrusion. Excessive incisor display may be due to the scarring, shrinkage, and shortening of the upper lip after surgery and/or due to extrusion of upper incisors. Facial appearance of a patient with short upper lip improved due to the intrusion of upper front teeth.
In general, adult patients undergoing orthodontic intrusion are more likely to have apical root resorption. Risk factors for root resorption include treatment duration, magnitude of applied force, method of force application, roots with developmental abnormalities, alveolar bone density, patient age and sex.
In our case, to prevent root resorption, incisor intrusion was done with mild activation of intrusion arch. Ricketts intrusion arch made of 0.016” × 0.022” TMA wire that provided lighter force for longer duration was used. When a mandibular first molar is lost, orthodontic mesialization with second and third molars is an excellent treatment option. The orthodontic procedures, prosthetic rehabilitation, and final nose and lip revision resulted in a near normal dental occlusion with significant improvement in esthetics and psychosocial benefits to the individual.
| Summary|| |
This case report shows a successful interdisciplinary treatment of adult BCLP patient.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khosla RK, McGregor J, Kelley PK, Gruss JS. Contemporary concepts for the bilateral cleft lip and nasal repair. Semin Plast Surg 2012;26:156-63.
Berkowitz S, editor. Complete bilateral cleft lip and palate. In: Cleft Lip and Palate, Diagnosis and Management. 2nd
ed. USA: Springer; 2006. p. 99-102.
Aburezq H, Daskalogiannakis J, Forrest C. Management of the prominent premaxilla in bilateral cleft lip and palate. Cleft Palate Craniofac J 2006;43:92-5.
Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 1. Evolution of the concept and dynamic records for smile capture. Am J Orthod Dentofacial Orthop 2003;124:4-12.
Kharbanda OP, editor. Clinical evaluation. In: Diagnosis and Management of Malocclusion and Dentofacial Deformities. 2nd
ed. India: Elsevier; 2013. p. 159.
Phadkule SS, Shivaprakash G, Kumar GA, Shamnur N. Customised appliance for intrusion and retraction of premaxilla in bilateral cleft palate patient. J Indian Orthod Soc 2014;48:561-5.
Fukunaga T, Honjo T, Sakai Y, Sasaki K, Takano-Yamamoto T, Yamashiro T. A case report of multidisciplinary treatment of an adult patient with bilateral cleft lip and palate. Cleft Palate Craniofac J 2014;51:711-21.
Ferrari Júnior FM, Ayub PV, Capelozza Filho L, Pereira Lauris JR, Garib DG. Esthetic evaluation of the facial profile in rehabilitated adults with complete bilateral cleft lip and palate. J Oral Maxillofac Surg 2015;73:169.e1-6.
Weltman B, Vig KW, Fields HW, Shanker S, Kaizar EE. Root resorption associated with orthodontic tooth movement: A systematic review. Am J Orthod Dentofacial Orthop 2010;137:462-76.
Baik UB, Chun YS, Jung MH, Sugawara J. Protraction of mandibular second and third molars into missing first molar spaces for a patient with an anterior open bite and anterior spacing. Am J Orthod Dentofacial Orthop 2012;141:783-95.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]