Orthodontic Treatment of Unilateral Cleft Lip and Palate Associated with Agenesis of Maxillary Lateral Incisors: A Case Report

Orofacial clefts: treatment based on a multidisciplinary approach

Objective : Many studies have demonstrated a high frequency of dental anomalies in patients with cleft lip and/or palate. Because dental anomalies may complicate dental treatment, we investigated the prevalence of dental anomalies in a group of Brazilian patients with nonsyndromic cleft lip and/or palate. Design, Participants, Setting : Retrospective analysis was performed using clinical records of 296 patients aged between 12 and 30years with repaired nonsyndromic cleft lip and/or palate without history of tooth extraction and orthodontic treatment. Associations between oral clefts and presence of dental anomalies outside the cleft area were investigated. Results : Dental anomalies were identified in 39.9% of the nonsyndromic cleft lip and/or palate patients, and tooth agenesis (47.5%), impacted tooth (13.1%), and microdontia (12.7%) were the most common anomalies. Cleft lip patients were less affected by dental anomalies compared with cleft palate or cleft lip and palate patients (p = .057). Specifically, patients with unilateral cleft lip and palate were significantly more affected by dental anomalies than those with bilateral cleft lip and palate (p = .00002), and individuals with unilateral complete cleft lip and palate (p = .002) and complete cleft palate (p = .01) were significantly more affected by tooth agenesis than other cleft types. Agenesis of the premolars (p = .043) and maxillary lateral incisors (p = .03) were significantly more frequent in patients with unilateral complete cleft lip and palate. Conclusions : The present study revealed a high frequency of dental anomalies in nonsyndromic cleft lip and/or palate patients and further demonstrated that patients with unilateral cleft lip and palate were frequently more affected by dental anomalies than those with bilateral cleft lip and palate. Moreover, our results demonstrate that dental anomalies should be considered during dental treatment planning for individuals affected by nonsyndromic cleft lip and/or palate.

Background: Dental anomalies is common feature of cleft lip and palate cases. Clefting is not an isolated condition but rather part of a broader spectrum of malformations involving both facial structures and tooth developmentObjective: To determine and compare the frequency of dental anomalies among children with unilateral and bilateral cleft palateMaterials and Methods: This cross-sectional descriptive study was conducted at the outpatient department of Bacha Khan Dental College, Mardan, involving 82 participants aged 4 to 20 years. Patient history, clinical examination, and panoramic radiographs were employed to identify common dental anomalies, like lateral incisor agenesis, supernumerary teeth, peg-shaped lateral incisor, lateral incisor microdontia, agenesis of the maxillary second premolar, and enamel hypoplasia. The Chi-square test was used to compare dental anomalies between unilateral and bilateral cleft palate cases, with the significance level set at p < 0.05.Results: The age was 12.12 ± 5.21 years, with a gender distribution of 28 (34.15%) females and 54 (65.85%) males. Unilateral cleft palate (n=56, 68.29%) was more common than bilateral (n=26, 31.71%). The frequency of dental anomalies included 37.80% exhibiting lateral incisor agenesis, 21.95% supernumerary teeth, 17.07% peg-shaped lateral incisor, 17.07% lateral incisor microdontia, 20.73% agenesis of the second premolar, and 9.76% clinical enamel hypoplasia. No statistical significant difference was found for all dental anomalies between unilateral and bilateral cleft palate (p>0.05).Conclusion: Dental anomalies are quite prevalent in both unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) patients. Importantly, no statistically significant differences were observed between these two groups.Keywords: Bilateral, Cleft lip and palate, Dental anomalies, Unilateral.

Cleft-orthognathic surgery

Introduction: Patients with orofacial clefts are usually associated with various dental anomalies. These dental aberrations pose a clinical challenge in treatment planning. Thus, this investigation intends to find the prevalence rate of different types of dental anomalies and their correlation among nonsyndromic cleft patients. Methodology: Orthodontic records of 129 cleft patients classified into different cleft groups were assessed to evaluate the presence of different dental anomalies. Results: The most frequent dental anomaly found in Cleft patients was rotations followed by maxillary lateral incisor agenesis with a prevalence rate of 90.4% and 59.2%, respectively. Maxillary second premolar agenesis, peg-shaped laterals, mandibular second premolar agenesis, and supernumerary teeth showed prevalence rates as 25%, 21%, 7%, and 5%, respectively. There were significant differences in the overall distribution of maxillary lateral incisor agenesis and rotations between patients with Unilateral Cleft Lip and Cleft Palate, Bilateral Cleft Lip and Cleft Palate, Cleft Lip (CL), and Isolated Cleft Palate (ICP). Conclusion: There is a high prevalence of dental anomalies like rotations and maxillary lateral incisor agenesis in different CL and palate patients, which were statistically significant. The presence of such anomalies can deteriorate the already existing functional problem and hence, the study of these anomalies and their treatment is an important step in the rehabilitation of such patients.

A comparison of growth impairment and orthodontic results in adult patients with clefts of palate and unilateral clefts of lip, palate and alveolus

Objective: The purpose of this study was to deter-mine the prevalence of agenesis and malformation of maxillary lateral incisors in orthodontic patients. Study design: Cross sectional study. Place and Duration of Study: Department of Ortho-dontics, Faculty of dentistry, the University of Lahore, Pakistan; from January 2007 to march 2010. Patients and Methods: The data (history sheets, dental casts and panoramic radiographs) of 230 pati-ents (36.5% males, 63.5% females; mean age: 16.4 years) were randomly selected from orthodontic pati-ent's record. Congenital absence, size and shape of maxillary lateral incisors was noted. Patients with cleft lip and palate, ectodermal dysplasia or having any syndrome were excluded from the study. Results: The prevalence of small size lateral incisors was 5.6%. The prevalence of peg lateral was 1.3% and agenesis of maxillary lateral incisors was found in 2.17% of the patients. Conclusion: The prevalence of small maxillary lateral incisors is high as compared to other lateral incisor anomalies. Key words: Prevalence, maxillary lateral incisors, malformation.

To assess the nasopharyngeal airway volume, cross-sectional area, and depth in previously repaired nonsyndromic unilateral cleft lip and palate versus bilateral cleft lip and palate patients compared with noncleft controls using cone-beam computed tomography with the ultimate goal of finding whether cleft lip and palate patients are more liable to nasopharyngeal airway obstruction. A retrospective analysis comparing bilateral cleft lip and palate, unilateral cleft lip and palate, and control subjects. Significance at P ≤ .05. Cleft Care Center and the outpatient clinic that are both affiliated with our faculty. Cone-beam computed tomography data were selected of 58 individuals aged 9 to 12 years: 14 with bilateral cleft lip and palate and 20 with unilateral cleft lip and palate as well as 24 age- and gender-matched noncleft controls. Volume, depth, and cross-sectional area of nasopharyngeal airway were measured. Patients with bilateral cleft lip and palate showed significantly larger nasopharyngeal airway volume than controls and patients with unilateral cleft lip and palate (P < .001). Patients with bilateral cleft lip and palate showed significantly larger cross-sectional area than those with unilateral cleft lip and palate (P < .001) and insignificant cross-sectional area compared with controls (P > .05). Patients with bilateral cleft lip and palate showed significantly larger depth than controls and those with unilateral cleft lip and palate (P < .001). Patients with unilateral cleft lip and palate showed insignificant nasopharyngeal airway volume, cross-sectional area, and depth compared with controls (P > .05). Unilateral and bilateral cleft lip and palate patients did not show significantly less volume, cross-sectional area, or depth of nasopharyngeal airway than controls. From the results of this study we conclude that unilateral and bilateral cleft lip and palate patients at the studied age and stage of repaired clefts are not more prone to nasopharyngeal airway obstruction than controls.

The purpose of this study was to compare the effect of the Latham-Millard presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion protocol with conservative treatment (nonpresurgical orthopedics without gingivoperiosteoplasty) for palatal and dental occlusion in complete bilateral and complete unilateral cleft lip and palate. All patients were from the South Florida Cleft Palate Clinic. A retrospective dental occlusal study was conducted using serial dental casts that had been taken of patients from birth to 12 years of age. All surgical procedures, except for the secondary alveolar bone grafts in the conservative, nonpresurgical orthopedics group, were performed by D. Ralph Millard, Jr. Ralph Latham supervised the presurgical orthopedics cases. Samuel Berkowitz collected and analyzed all the serial records from 1960 to 1996. Among the patients with complete unilateral cleft lip and palate, 30 patients were treated with presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (the Latham-Millard protocol) and 51 patients were treated conservatively (i.e., nonpresurgical orthopedics without gingivoperiosteoplasty). Among the patients with complete bilateral cleft lip and palate, 21 patients were treated with the Latham-Millard protocol and 49 patients were treated conservatively. Conservative treatment was performed between 1960 and 1980. In patients with bilateral cleft lip and palate, a head bonnet with an elastic strip was used to ventroflex the protruding premaxilla. In all patients (unilateral and bilateral cleft), lip adhesion was performed at 3 months followed by definitive lip surgery at 6 to 8 months and palatal cleft closure between 18 and 24 months of age, in most cases. The Latham-Millard procedure was performed from 1980 to 1996; in bilateral cleft patients, it involved the use of a fixed palatal orthopedic appliance to bodily retract the protruding premaxilla and align it within the alveolar segments soon after birth. In all patients (unilateral and bilateral cleft), palatal alignment was also followed by gingivoperiosteoplasty and lip adhesion. Definitive lip surgery was performed between 6 and 8 months of age, and palatal closure was performed between 8 and 24 months of age using the von Langenbeck procedure with a modified vomer flap. All of the study participants had cleft lips and palates of either the unilateral or bilateral type; the unilateral and bilateral groups were further subdivided based on whether they had received the Latham-Millard protocol or the conservative treatment. It was then determined how many in each of these four basic groups had either anterior or buccal crossbites at four different age levels, when they were approximately 3, 6, 9, and 12 years of age. Although several children entered the study at or just before age 6, every patient in the 9-year-old and 12-year-old sample groups had been in the 6-year-old group and all of the 12-year-olds had been included in the immediate preceding age sample. Two-by-two chi-square tests were carried out within each cleft type (unilateral or bilateral) at each of the four age levels separately, to test whether the treatment groups (protocol versus conservative) differed in the frequency of cases with a given kind of crossbite (rather than not having that kind of crossbite). At every age level, a greater percentage of patients treated with the Latham-Millard protocol developed crossbites than did those treated more conservatively. This difference existed for both the anterior and buccal crossbites and for both unilateral and bilateral clefts. Chi-square tests of the treatment differences in crossbite frequency showed that in three quarters of the Latham-Millard protocol versus conservative treatment comparisons (12 out of 16), a significantly greater frequency of crossbite cases occurred after the Latham-Millard protocol treatment as compared with after the conservative procedure. The chi-square values for the differences in outcome between the two kinds of treatment procedures were greater for the anterior crossbites than for the buccal crossbites, suggesting that the Latham-Millard protocol, relative to the conservative method, was more likely to have an adverse effect on the anterior crossbites than on the buccal crossbites. For those patients born with a bilateral cleft, the differences in crossbite frequency between the protocol and the conservative treatment were statistically significant for patients with an anterior crossbite but not for patients with a buccal crossbite. The analysis shows that in complete bilateral and unilateral cleft lip and palate, the frequency of the anterior crossbite and (except for ages 3 and 12) the buccal crossbite is significantly higher with the Latham-Millard presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion protocol compared with the conservative, nonpresurgical orthopedics without gingivoperiosteoplasty treatment. The exception in the bilateral buccal case may be attributed to the small experimental sample size, which brings down the confidence level.

Background: This retrospective case-control study was done to investigate the cranio-dento-facial morphology of Turkish children with unilateral complete cleft lip and palate from Ege University and compare them with a normal group to highlight the effect of surgical correction on craniofacial development. Methods: 60 patients with unilateral complete cleft lip and palate were compared with 55 control children without cleft at mean ages of 13 and 15 years. The cleft lip was operated with modified Millard technique at 3 months, cleft palate was operated with von Langenbeck technique at 12 months. The patients were not given any orthopaedic or orthodontic treatment also. Angular and linear measurements of cranio-dento-facial complex were measured by using Dolphin Imaging 11.5 software programme, and the resulting data were evaluated statistically. Results: The children with unilateral complete cleft lip and palate had considerable morphological deviations when compared with the matched children without clefts. The most striking findings in the unilateral complete cleft lip and palate group: Maxillary and mandibular complex and nasal projections were retruded when compared with normal (P<0.001). Also, nasal airway dimensions were higher in control group (P<0.001). Soft tissue structure, especially upper lip thickness, upper and lower lip lengths were decreased (P<0.001, P<0.001, P<0.05, respectively) in cleft group. Maxillar anterior height was decreased (P<0.001). Besides, nasolabial angle and upper incisor inclination according to the maxillary occlusal plane (P<0.001) were increased while overjet (Mx1-Md1) were decreased (P<0.001). Conclusion: The surgical technique and the number of operations seem to be the most effective factors for maxillary retrusion in patients with unilateral complete cleft lip and palate.

To demonstrate a standardized approach for the evaluation of cleft lip and palate by three-dimensional (3D) ultrasonography. This was a retrospective study of seven fetuses with confirmed facial cleft anomalies. Post-natal findings were compared to a blinded review of 3D volume data from abnormal fetuses with seven other normal fetuses that were matched for gestational age. Upper lip integrity was examined by 3D multiplanar imaging. Sequential axial views were used to evaluate the maxillary tooth-bearing alveolar ridge contour and anterior tooth socket alignment. Alveolar ridge disruption suggested cleft palate. Premaxillary protrusion, either by multiplanar imaging or surface rendering, indicated bilateral cleft lip and palate. Post-natal findings confirmed bilateral cleft lip and palate (four cases), unilateral cleft lip and palate (one case), and unilateral cleft lip (two cases). Multiplanar review identified all three fetuses with unilateral cleft lip, three of four fetuses with bilateral cleft lip, one fetus with unilateral cleft palate, and three of four fetuses with bilateral cleft palate. Surface rendering correctly identified all cleft lips, with the exception of one fetus, who was thought to have a unilateral cleft lip and palate, despite the actual presence of a bilateral lesion. One cleft palate defect was directly visualized by 3D surface rendering. No false-positives occurred. Interactive review of standardized 3D multiplanar images allows one to evaluate labial defects, abnormalities of the maxillary tooth-bearing alveolar ridge, and presence of premaxillary protrusion for detecting cleft lip and palate anomalies. Surface rendering may increase diagnostic confidence for normal or abnormal studies. This technology provides an array of visualization tools that may improve the prenatal characterization of facial clefts, particularly of the palate.

Stereophotogrammetry to evaluate young adults with and without cleft lip and palate after orthodontic and restorative treatment

To investigate associations between cleft lip anthropometrics and dental anomalies in the permanent dentition in unilateral cleft lip patients. Retrospective cross-sectional study. Children with unilateral clefts of the lip, with or without cleft palate. Anthropometric lip measurements, made immediately prior to lip repair, were available for each patient. The presence of dental anomalies in the permanent dentition was assessed radiographically. The presence of associations between anthropometric lip measurements and prevalence rates of different dental anomalies were determined using logistic regression analyses. In the 122 included patients, the cleft lateral lip element was deficient in height in 80% and in transverse length in 84% of patients. Patients with more deficient cleft side lateral lip height and less deficient cleft side lateral lip transverse length were more likely to present with cleft side maxillary lateral incisor agenesis. On the other hand, patients with a less deficient cleft side lateral lip height and more deficient cleft side lateral lip transverse length were more likely to present with a cleft side supernumerary maxillary lateral incisor. When looking only at incomplete clefts, the cleft side lateral lip transverse length deficiency was more predictive of the presence of supernumerary maxillary lateral incisors (P = .030), while for complete clefts, the cleft side lateral lip height deficiency was more predictive of the presence of maxillary lateral incisor agenesis (P = .035). In patients with unilateral clefts, cleft lip anthropometrics have a predictive role in determining the occurrence of dental anomalies.

The objective of this study was to evaluate the craniofacial morphology of children with unilateral cleft lip and palate (UCLP) resulting from differing management protocols practiced in Prague from 1945 to 1976. The craniofacial morphologies of four groups of patients were compared. Two groups were assessed retrospectively (individuals born from 1945 to 1963), and two groups were followed on a longitudinal basis (individuals born from 1966 to 1976). The study was conducted at the Cleft Lip and Palate Center at the Department of Plastic Surgery, Prague, which has a catchment area population of 6 million. The subjects were a consecutive series of adult males (n = 84) who had complete UCLP without associated malformations. Patients born from 1945 to 1955 did not receive centralized orthodontic therapy. From 1945 to 1965, the alveolar process in the area of the cleft was not surgically repaired. Primary bone grafting was used for the group born from 1965 to 1972, and primary periosteoplasty was used in the subsequent period. Throughout the period covered by the study, the palate was operated on by pushback and pharyngeal flap surgery. From 1945 to 1965, the lip was repaired initially according to Veau, and later according to Tennison and Randall, and during this time, fixed appliances were used for orthodontic treatment. The results for the period from 1945 to 1955 are characterized by mandibular overclosure with anterior crossbite. Centralized orthodontic treatment in the later period improved sagittal jaw relations due to the posterior displacement of the mandible and an edge-to-edge bite was attained, but maxillary retrusion was unchanged. Primary bone grafting increased retrusion of the maxilla, which was compensated by further posterior displacement of the mandible. An edge-to-edge bite was also obtained. Primary periosteoplasty reduced maxillary retrusion, and the marked proclination of the upper dentoalveolar component with fixed appliances resulted in a positive overjet. It was no longer necessary to push the mandible back to the extent required in bone grafting. Effective orthodontic treatment made the greatest contribution to improved facial development. It allowed compensation of maxillary retrusion by changes in the position of the mandible or by proclination of the upper dentoalveolar component with fixed appliances. The applied surgical methods using primary bone grafting caused deterioration of the anterior growth of the maxilla.

To investigate whether the craniofacial vertical and sagittal jaw relationship in patients with cleft lip and palate (CLP) differed from that of age-matched noncleft controls, before and after the pubertal growth spurt. Retrospective observational study. The study group comprised 126 patients with CLP, subdivided according to gender and cleft type, and the control group comprised 53 age-matched skeletal class I patients. Angular and linear measurements were taken from prepubertal and postpubertal lateral cephalograms of all patients. In patients with cleft lip and palate, the maxillary retrognathism became more remarkable with increasing age; whereas, the retrognathic position of the mandible became less pronounced as compared with controls. Reduced posterior midfacial height, a common prepubertal finding in patients with cleft lip and palate, was significant in postpubertal girls and young women with unilateral cleft lip and palate (p = .002). The total anterior facial height in male patients with bilateral cleft lip and palate was larger than in control patients (p = .002) after the pubertal growth spurt due to an increased anterior midfacial height. In male patients with unilateral cleft lip and palate, this finding was due to an increased anterior lower facial height (p < .001). Patients with cleft lip and palate treated according to a standardized treatment concept had adequate craniofacial jaw relationships after puberty. Despite a measured skeletal class I in both male and female patients with cleft lip and palate regardless of cleft type, there was a slight tendency toward a skeletal class III. Findings were similar for all groups of cleft lip and palate patients irrespective of the type of orthodontic treatment performed.