oral rehabilitation of an orthodontic patient with cleft lip and palate
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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-
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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.
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