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ORTHODONTIC TREATMENT OF CLEFT

LIP AND ALVEOLUS USING SECONDARY

AUTOGENOUS CANCELLOUS BONEGRAFTING:A CASE REPORT

Aim:This paper concerns orthodontic alignment of the maxillary lat-

eral incisor on the cleft side of a lip and alveolar cleft patient after a

secondary autogenous cancellous bone graft at the late stage of

mixed dentition. Subject and Treatment: The patient was a Japanese

girl 9 years 7 months of age who presented at the authors clinic with

a repaired lip and alveolar cleft and an incisor crossbite. At 12 years of

age, a secondary bone graft of the alveolar ridge was performed

using bone harvested from the iliac crest. At 14 years 7 months of age,

a conventional fixed appliance was placed. Results: The lateral incisor

on the cleft side was brought to the line of occlusion by orthodontic

alignment. A Class I molar relationship on both sides and a satisfac-

tory facial profile were achieved. After a 2-year retention period, the

occlusion and esthetics were maintained. Five years after grafting,

however, a satisfactory bone level was not achieved due to position-

ing of the root of the lateral incisor, which was not completely upright

in the bone graft area due to root tipping. World J Orthod 2009;

10:6775.

Takashi S. Kajii, DDS, PhD1

Mohammad K. Alam, DDS2

Junichiro Iida, DDS, PhD3

Cleft lip and palate patients usually

require orthodontic treatment to

improve midfacial retrusion due to an

unfavorable growth inhibition of the

craniofacial complex.15 Cleft lip and

alveolus patients also occasionally show

an Angle Class I I I malocclusion,

although not generally severe. Mal-

formed teeth adjacent to the cleft area

are common. In addition, lateral incisors

adjacent to the cleft are commonly

deformed or absent.6

Secondary bone grafting is now a rou-

tine procedure for the treatment of cleft

lip and alveolus (and palate) cases. Sec-

ondary autogenous cancellous bone

grafting is generally performed at the

late stage of the mixed dentition,7,8 but

in recent years, it has also been per-

formed at the early stage of mixed denti-

ti on . The newly graf ted bo ne shows

orthodontic benefits by acting as the

alveolus, which allows for spontaneous

migration of either or both the canine

and lateral incisor toward the alveolar

ridge.710 Satisfactory long-term results

of secondary bone grafting have been

reported.11

We present a case of orthodontic

alignment of the maxillary lateral incisor

on the cleft side after a secondary auto-

genous cancellous bone graft at the late

mixed-dentition stage.

SUBJECT AND TREATMENT

History and diagnosis

A Japanese girl first presented at our

institution at 9 years 7 months of age

with a unilateral left lip and alveolar cleft.

1Assistant Professor, Department of

Orthodontics, Graduate School of

Dental Medicine, Hokkaido Univer-

sity, Sapporo, Japan.2Graduate Student, Department of

Orthodontics, Graduate School of

Dental Medicine, Hokkaido Univer-

sity, Sapporo, Japan.3Professor and Chair, Department of

Orthodontics, Graduate School ofDental Medicine, Hokkaido Univer-

sity, Sapporo, Japan.

CORRESPONDENCE

Dr Takashi S. Kajii

Department of Orthodontics

Division of Oral Functional Science

Graduate School of Dental Medicine

Hokkaido University

Kita 13 Nishi 7 Kita-ku

Sapporo 060-8586 Japan

Fax: 81-11-706-4917

Email: [email protected]

COPYRIGHT 2008 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO

PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER

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At the age of 6 months, she underwent

cheiloplasty using a modified Millard tech-

nique at the Plastic Surgery of Hokkaido

University Hospital, Sapporo, Japan. Her

main complaint was esthetic: an anterior

crossbite. No speech disorder, temporo-

mandibular disorder symptoms, or any

other significant medical history was

observed.

The patient presented a symmetrical

face with a concave profile showing func-

tional anterior protrusion of the mandible

(Fig 1) due to premature contact between

the maxi llary and mandibular centra l

incisors (Figs 2 and 3). The maxillary and

mandibular dental midlines were almost

coincident with the facial midline and the

maxillary left central incisor was rotated.

The molar relationship was Angle Class III

on both sides (Fig 2b).

Panoramic radiography (Fig 3) and peri-

apical projection revealed an alveolar cleft

on the maxillary left side and a peg-

shaped maxillary left lateral incisor. Lat-

eral cephalometric analysis showed a

skeletal Class I type, a slightly high angle

facial configuration, as well as lingual incli-

nation of the maxillary incisor (Table 1).

The patient was therefore diagnosed

as Angle Class III, skeletal Class I maloc-

clusion with functional anterior protru-

sion of the mandible.

68

Kajii et al WORLD JOURNAL OF ORTHODONTICS

Fig 1 Pretreatment (top, 9 years 7 months of age) and midtreatment (bottom, 14 years 7 months of age).



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VOLUME 10, NUMBER 1, 2009 Kajii et al

Fig 2 (a) Pretreatment without functional anterior position of the mandible, (b) pretreatment (9 years 7 months), and(c) midtreatment (14 years 7 months).

a

c

b



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Treatment plan

Phase 1 of treatment consisted of labial

inclination of the maxillary central and

right lateral incisors using a lingual arch

appliance to eliminate the anterior cross-

bite, as well as a posterior bite plate on

the mandibular arch to el iminate any

interference between the incisors. Sec-

ondary autogenous cancellous bone graft

of the alveolar ridge was then planed

before eruption of the maxillary left lat-

eral incisor using bone harvested from

the iliac crest.

Phase 2 consisted of nonextraction,

tooth alignment, and achievement of an

ideal occlusion using a fixed appliance,

followed by retention.

Treatment progress

At 9 years 7 months of age, a lingual arch

appliance and posterior bite plate were

placed in the maxillary and mandibular

dental arches, respectively; the posterior

bite plate was removed 3 months later.

Six months later, activation of the spring

section of the lingual arch was discontin-

ued, followed by placement of a new lin-

gual arch for 3 years, which served as a

retainer. The sequence of tooth eruption

was monitored by periodical examination.

At 12 years of age, a secondary bone

graft of the alveolar ridge was performed

at Hokkaido University Hospital using

bone harvested from the iliac crest.

Although the maxillary left canine had

erupted, the maxillary left lateral incisor

had not, and formation of the root of the

lateral incisor was only two-thirds

complete.

Before initiation of the second phase

of orthodontic treatment at 14 years and

7 months of age, the patient was diag-

nosed with skeletal Class I and Angle

Class II subdivision (right) occlusion (Figs

1, 2c, and 3). In addition, spontaneous

eruption of the maxillary left lateral

incisor into the grafted bone area was

observed. Phase 2 of the treatment plan

was carried out as initially planned. Prior

70


Fig 3 (a) Pretreatment (9 years 7months), (b) pretreatment withoutfunctional anterior position ofmandible, and (c) midtreatment(14 years 7 months) radiographs.

a

b

c



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to placing a fixed edgewise appliance, a

distalizing zig was inserted on the maxil-

lary r ight s ide (Fig 4) . The z ig was

removed, followed by placement of a

fixed edgewise appliance (0.022

0.028 in, preadjusted). During the level-

ing period, the maxillary left lateralincisor was brought to the line of occlu-

sion by orthodontic forces. The maxillary

right premolar was moved distally using

an open coil spring, followed by the

canine and lateral incisor. Respective

wire sequence was then selected, and

intermaxillary elastics were used.

Ideal occlusion was achieved at 18

years 4 months of age (Figs 5, 6a, and

7), and all appliances were removed.

Begg and Hawley-type retainers were

placed in the maxillary and mandibulararches, respectively. To maintain over-

bite, a tooth positioner was placed 1 year

later for a period of 4 months.

RESULTS

Results show that treatment based on

pretreatment planning was successful.

The facial profile of the patient was

improved (Fig 5), solid intercuspation of

the teeth and a Class I molar relationship

were achieved (Fig 6a). Also, the negative

overjet was corrected. Panoramic radiog-

raphy and periapical projection after

treatment showe d no root resorption

(Figs 7 and 8). During treatment, the

patient showed no temporomandibulardisorder symptoms. The left lateral

incisor was prosthetically restored using

a resin veneer, and the line of occlusion

was esthetically satisfactory. Two years

after the retention period, an acceptable

facial profile and occlusion was main-

tained (Figs 5, 6b, 7, and 9).

DISCUSSION

The intercuspation between the teeth

was satisfactory. The molar relationship

was Class I, and overjet and overbite

were ideal, with an improved arch form

and alignment. Both the maxillary and

mandibular dental midlines were nearly

aligned with the facial midline. In this

case, results would have been less satis-

factory if the patient had presented with

a palatal cleft in addition to the alveolar

cleft.

Fig 4 Orthodontic correction.

Table 1 Cephalometric measurements

Pretreatment Interim Posttreatment 2 y after debond

9 y 7 mo 14 y 7 mo 18 y 4 mo 20 y 8 mo

SNA (degrees) 80.0 81.0 81.0 81.0

SNB (degrees) 77.2 77.5 77.8 77.9

ANB (degrees) 2.8 3.5 3.1 3.1

FMIA (mm) 57.8 57.6 54.6 53.1

IMPA (mm) 89.9 88.7 92.1 93.6

FMA (mm) 32.3 33.7 33.3 33.3

FH to occlusal (degrees) 14.2 9.6 10.2 11.0

U1-SN (degrees) 84.7 104.9 107.9 104.7Interincisal angle (degrees) 146.9 126.2 120.5 122.4



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Bone grafting is typically performed

between 9 and 11 years of age, shortly

before canine eruption.7 In the present

subject, maturation of the lateral incisor

and canine on the cleft s ide was

reversed: at 12 years of age, bone graft-

ing was performed after canine eruption

for the lateral incisor rather than for the

canine.

The peg-shaped lateral incisor on the

cleft side was successfully moved to the

line of occlusion. If bone grafting had not

been performed on this patient, maxillary

left lateral incisor extraction and bridge-

work in the space would have been

required, unless the need for bone graft-

ing had been obviated due to a consider-

ably narrow bone defect.12 In the present

subject, bone grafting contributed to the

preservation of teeth, as well as

improved rotation of the central incisor

on the cleft side.

Five years after grafting, however, a

satisfactory bone level was not achieved

(Fig 8). If the root of the lateral incisor of

cleft side also would have spontaneously

erupted into the grafted bone area, the

grafted bone would have been main-

tained for a longer period of time.11,13,14

In the present subject, however, displace-

ment of the lateral incisor root using

orthodontic force was necessary. Failure

to maintain the grafted bone was possi-

bly due to the position of the lateral

incisor root in the bone graft area, which

was not completely upright.

Two and a half years after grafting, the

root of the lateral incisor was completed

72


Fig 5 Posttreatment (top row, 18 years 4 months of age) and 2 years posttreatment (bottom row, 20 years 8 months of age).



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73


(Fig 8) with root tipping, which was one of

the difficult factors in root movement in

the grafted area. Provision of superior

periodontal support to adjacent teeth will

require evaluation of the long-term stabil-

ity of the grafted bone.

ACKNOWLEDGMENTS

The authors would like to thank Associate Prof

Yosh iak i Sa to (D ep ar tm en t of Or th od on ti cs ,

Hokkaido University), Dr Kunihiro Kawashima (plas-

tic surgery, Sapporo City Hospital), and Dr Hiroharu

Igawa for their contributions to this report.

Fig 6 (a) Posttreatment (18 years 4 months of age) and (b) 2 years after posttreatment (20 years 8 months of age).

b

a



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Fig 7 (a) Posttreatment (18 years 4months of age) and (b) 2 years post-treatment (20 years 8 months of age)radiographs.

Fig 8 Periapical radiographs. From left: pretreatment, just before bone graft (12years of age), 3 months after grafting, midtreatment, posttreatment, and 2 yearsposttreatment.

Fig 9 Cephalometric superimposition.

Pretreatment

Interim

Posttreatment

2 y after debond

a

b



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