Multidisciplinary approach for cleft alveolus and impacted canine.
Cleft patients have markedly higher frequency of congenitally missing and impacted permanent teeth as compare to the normal population. (1,2) The incidence of congenitally missing permanent lateral incisors within the alveolar cleft is between 35 and 60% (3) and the frequency of these congenitally missing teeth are higher in girls than in boys (4,5) It is reported by the many researchers that most frequently missing teeth in cleft patients are the maxillary lateral incisors in the cleft region and the maxillary second premolars outside the cleft region. (1)
Maxillary canines are the most commonly impacted teeth. (6,7) It occurs in approximately 2% of the normal population and is twice as common in females than in males. (8,9) Again its incidence in the maxilla is more than twice that in the mandible. (9) Patients with alveolar clefts had a 20-fold increased risk for canine impaction. (10) In this reported case a comprehensive multidisciplinary approach was undertaken to manage a unilateral cleft alveolus with congenitally missing maxillary lateral incisor and canine impaction of same side in a 19 years old young girl.
A 19 year-old girl was reported in a dental clinic for the unpleasing smile (Figure-1A)because of her unilateral cleft lip and alveolus of left side of maxilla in which surgical correction done 12 years back. On clinical examination (Figure-2A) it was revealed that she had missing maxillary left lateral incisor (22), hypoplastic left central incisor (21) and retained maxillary deciduous left canine (63). The clinical examination also revealed Angle Class I molar relationship with deep bite (Figure-2A) and crowding in lower anterior segment. The permanent left maxillary canine (23) was not visible in the arch.
The radiological examination (0PG) showed (Figure-1E) that the 23 was impacted, situated almost vertically and the crown was directed obliquely mesially into the arch. A clear bony defect (Figure-1F) was observed along the cleft in upper standard occlusal radiograph.
The objective of treatment was to provide a esthetic profile by preparing an adequate space for an ideal pontic with gingival prosthesis for missing 22 with bony defect and proper positioning of the impacted 23 into the arch to obtain a well alignment.
As because the lower teeth were in crowding condition with a stiff curve of spee, so treatment was also planned for crowding and deep bite correction in the lower dental arch.
After necessary pre surgical investigations decision was made to perform orthodontic extrusion of impacted 23 by surgical exploration of the crown of 23. Begs' brackets were placed in upper and lower teeth pre-surgically. A full thickness muco-periosteal flap was elevated from 21 to 24 region under local anaesthesia, extraction (Figure-3A) of retained 63 was done and crown of 23 was discovered just after removing a shell of bone from labial cortex. A Begs' orthodontic bracket was placed on 23 and suturing done (Figure-3B).
As the suture removal done after 7 days, orthodontic traction was started with the help of a E-chain and arch wire (Figure-3C&D). A 0.014mm NiTi wire was used in lower ach for the correction of crowding. With in 7 months orthodontic extrusion of 23 was completed (Figure-4A) and angulation with vertical axis was corrected by the use of two E-chains (Figure-4B) along the arch in two halves of the edentulous space and by that way sufficient space was created for future 22 (pontic). The deep bite was corrected by incorporating anchorage bend (25[degrees]) in lower arch wire. After orthodontic correction of malocclusions, all brackets were removed and a modified Howley appliance (removable plate with attached acrilic lateral incisor for to hold the created space for 22) was given for six months as a retentive device. At the end a removable partial denture replacing 22 was given to the patient for next six months (Figure-4C) for better tissue adaptation.
At the end of six months vitality testing for 23 revealed positive response and an IOPA radiograph showed normal peri radicular area (Figure-1E). A fixed bridge was planned taking 21 and 23 as abutments for missing 22 and a ceramic gingival replacement was attached with the pontic for alveolar defect correction (Figure-5A,B,C,&D). The extracoronal full coverage porcelain fused to metal restoration on 21 helped to hide the hypoplastic defect (Figure-2D).
Maxillary permanent canines are important for an attractive smile and are also essential for a functional occlusion. Offering a pleasing esthetic appearance in a patient with cleft lip and alveolus is one of the toughest job in dental practice. Many a times over retention of deciduous canine makes the situation more difficult by impacting succedenious permanent canine. Surgical exposure of the impacted canine and the use of fixed orthodontic appliances is the most frequently used treatment alternative as long as the tooth position is favourable. Various methods have been used for bringing the canine into proper alignment. Fournier et al (11) have proposed the use of a removable plate. Becker and Zilberman (12) have recommended the use of a flexible palatal arch slotted into horizontal, soldered, palatal tubes on the molar bands of any type of fixed multibonded appliance. Jacoby (13) has suggested his ballista spring to direct a palatalocclusal force from the buccal side. In this reported case the extrusion was done with the help of a E-chain and a arch wire.
Considerable amount of bony defects in anterior region can be easily managed by prosthetic approach. A fixed gingival prosthesis (ceramic) or removable gingival prosthesis (acrylic) can eliminate invasive surgical procedure. (14) A xed prosthesis gives the patient signicant comfort and peace of mind, as well as self-condence (because the prosthesis is always present). However, its application may be limited to certain clinical situations where oral hygiene is manageable, the desired esthetic result is achievable or esthetics are not critical, and a xed prosthesis is already planned for the immediate area (14). A fixed coral pink coloured ceramic gingival prosthesis with the pontic replacing the missing 22 was planned in this reported case. The bony deficiency at the alveolar cleft was managed by the ceramic gingival prosthesis which was very aesthetc, highly polished and easy to maintain.
The total treatment time was 2 years and post operative followup was done for another one year. Orthodontic extrusion took almost 7 months which was almost one third of the total treatment span. During the treatment step by step correction of deep bite and lower incisors crowding were done in conventional technique.
Aesthetic correction of a patient with cleft lip and alveolus in is always a challenging job especially when the situation is complicated with over retained deciduous tooth and impacted permanent tooth. In this reported case a combination of Orthodontic, Prosthodontic and Surgical technique were advocated to get the ultimate pleasing smile. Only multidisciplinary approach and careful evaluation in each an every steps of treatment is mandatory for this kind of long term success. As because the cleft patients are belong to very low self esteemed group so least invasive treatment modality should need to be advocated for better tolerance.
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(13.) Jacoby H. The 'ballista spring" system for impacted teeth.Am J Orthod. 1979;75:143-151.
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Dulal Das 
 Senior Lecturer
Dept. Of Pedodontics And Preventive Dentistry, Kalinga Institute Of Dental Sciences, Bhubaneswar
Received: April 12, 2013
Review Completed: May 11, 2013
Accepted: June 10, 2013
Available Online: October, 2013 (www.nacd.in)
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|Publication:||Indian Journal of Dental Advancements|
|Article Type:||Case study|
|Date:||Jul 1, 2013|
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