Oral Rehabilitation of an Orthodontic Patient With Cleft Lip and Palate

8/13/2019 Oral Rehabilitation of an Orthodontic Patient With Cleft Lip and Palate

http://slidepdf.com/reader/full/oral-rehabilitation-of-an-orthodontic-patient-with-cleft-lip-and-palate 1/6

279

Oral Rehabilitation of an Orthodontic Patient With Cleft Lip and Palate and

Hypodontia Using Secondary Bone Grafting, Osseo-Integrated Implants,

and Prosthetic Treatment

SHINGO KAWAKAMI, D.D.S.

MASAHIKO YOKOZEKI, D.D.S., PH.D.SHINYA HORIUCHI, D.D.S.

KEIJI MORIYAMA, D.D.S., PH.D.

Objective: Complete skeletal and dental reconstruction of the anterior max-

illa is of great importance to patients with cleft lip and palate. Accordingly,

osseo-integrated implants have been utilized for dental reconstruction after

secondary bone grafting. In this report, the orthodontic management of a pa-

tient with unilateral cleft lip and plate with associated hypodontia is described.

The patient was treated with comprehensive orthodontic treatment in addition

to secondary bone grafting, and dental reconstruction was achieved with a

combination of osseo-integrated implants and fixed prosthodontic treatment.

KEY WORDS: congenital missing, orthodontic management, osseo-integrated

implant, SBG

Secondary bone grafting (SBG) of alveolar clefts in patients

with cleft lip and palate is thought to be a reliable and highly

predictable method of restoring the integrity of the alveolar

ridge. SBG may aid the spontaneous eruption of the teeth ad-

jacent to the cleft (Bergland et al., 1986; Paulin et al., 1988).

It also allows for the orthodontic movement of these teeth into

the correct position within the dental arch (Boyne and Sands,

1976; Enemark et al., 1985; Turvey et al., 1984). On the other

hand, when hypodontia occurs in patients with cleft lip andpalate, orthodontic treatment and dental reconstruction become

extremely difficult because of the limited number of teeth pre-

sent. On such occasions, a conventional fixed prosthesis or a

removable partial denture has often been used for the oral re-

habilitation of these patients. In recent years, osseo-integrated

implants after SBG have provided a new alternative for the

reconstruction of patients with cleft lip and palate. Previous

studies have shown that bone graft stability is an important

factor when performing restorative interventions into the graft-

ed bone (Kawakami et al., 2002; Rosenstein et al., 1997). Sat-

isfactory SBG results would pave the way for implant insertion

into the grafted bone (Ronchi et al., 1995; Takahashi et al.,

1997; Triplett and Schow, 1996). This report describes the or-

thodontic management of a patient with unilateral cleft lip and

Submitted January 2003; Accepted May 2003.

Address correspondence to: Keiji Moriyama, D.D.S., Ph.D., Department of

Orthodontics, School of Dentistry, University of Tokushima, 3-18-15, Kura-

moto-cho, Tokushima 770-8503, Japan. E-mail [email protected].

ac.jp.

palate with hypodontia treated with an osseo-integrated im-

plant and followed by prosthetic treatment after SBG.

CASE REPORT

The patient, an 11-year-old boy with a repaired left complete

unilateral cleft lip and palate (UCLP), was initially examined

at the Tokushima University Dental Hospital. Clinical exami-

nation revealed a Class III malocclusion with complete bilat-

eral posterior crossbite caused by a narrow maxillary arch as

well as an anterior crossbite. The right maxillary lateral incisor

had erupted ectopically in a palatal position (Fig. 1). Evalua-

tion of the panoramic radiograph showed that the maxillary

left lateral incisor, the left and right second premolars and first

molars, and the right third molar were congenitally missing

(Fig. 2). The lower dental midline was deviated to the left, and

the size of the alveolar cleft was quite large. Cephalometric

analysis showed a skeletal Class III relationship with a retrud-

ed maxilla point A-nasion-point B [ANB], 0.4 degrees; sella-

nasion-point A [SNA], 75.3 degrees) as well as maxillary and

mandibular incisors lingually tipped, as shown in Table 1.

TREATMENT

The treatment plan consisted of improving the complete

crossbite and correct the skeletal Class III relationship by an-

terior and lateral expansion of the maxillary arch and anterior

protraction of the maxilla. A quadhelix appliance for the max-

illary expansion in addition to orthopedic protraction of the

maxilla with a face mask were initially used. Standard edge-

wise appliances (0.018 0.025) were bonded to the maxillary

teeth for space maintenance and correction of crowding at the

age of 12 years 10 months. The anterior and posterior cross-





Kawakami et al., ORAL REHABILITATION OF AN ORTHODONTIC PATIENT 281

FIGURE 3 Intraoral views just before secondary bone grafting.

FIGURE 4 One year after secondary bone grafting. A. Intraoral view. B. Fixture placement. C. Abutment placement.

FIGURE 5 Posttreatment facial (A) and intraoral (B) views.







284 Cleft Palate–Craniofacial Journal, May 2004, Vol. 41 No. 3

dosseous implants in grafted alveolar clefts. Cleft Palate Craniofac J. 1997;

34:520–525.

Nakai H, Niimi A, Fujimoto T, Ueda M. Prosthetic treatment using an osseoin-

tegrated implant after secondary bone grafting of a residual alveolar cleft:

a case report. Int J Oral Maxillofac Implants. 1998;13:412–415.

Paulin G, Astrand P, Rosenquist JB, Bartholdson L. Intermediate bone grafting

of alveolar clefts. J Craniomaxillofac Surg. 1988;16:2–7.

Ranta R. A review of tooth formation in children with cleft lip/palate. Am J Orthod Dentofacial Orthop. 1986;90:11–18.

Ronchi P, Chiapasco M, Frattini D. Endosseous implants for prosthetic reha-

bilitation in bone grafted alveolar clefts. J Craniomaxillofac Surg. 1995;23:

382–386.

Rosenstein SW, Long RE Jr, Dado DV, Vinson B, Alder ME. Comparison of

2-D calculations from periapical and occlusal radiographs versus 3-D cal-

culations from CAT scans in determining bone support for cleft-adjacent

teeth following early alveolar bone grafts. Cleft Palate Craniofac J. 1997;

34:199–205.

Takahashi T, Fukuda M, Yamaguchi T, Kochi S. Use of endosseous implants

for dental reconstruction of patients with grafted alveolar clefts. J Oral Max-

illofac Surg. 1997;55:576–583.

Triplett RG, Schow SR. Autologous bone grafts and endosseous implants: com-

plementary techniques. J Oral Maxillofac Surg. 1996;54:486–494.Turvey TA, Vig K, Moriarty J, Hoke J. Delayed bone grafting in the cleft

maxilla and palate: a retrospective multidisciplinary analysis. Am J Orthod.

1984;86:244–256.

Verdi FJ Jr, Lanzi GL, Cohen SR, Powell R. Use of the Branemark implant in

the cleft palate patient. Cleft Palate Craniofac J. 1991;28:301–303.

Documents

Oral Rehabilitation of an Orthodontic Patient With Cleft Lip and Palate