2019, Number 4
Patient with cleft lip and palate sequela. Orthodontic and surgical treatment
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ABSTRACT
Clinical case report of a 23-year-old female patient, with the sequelae of cleft lip and palate. Class III skeletal, dolichofacial, hyperdivergent growth, concave profile, occlusal plane edging, whit anterior mandibular laterognasia and posterior crossbite, oronasal communication at the level of the upper left cuspid, right side with class I molar and class I canine, left side class I molar, cuspid class not assessable. Presurgical phase: we placed system Roth 0.022", extractions of dental organs 12 and 22, visual treatment objective (VTO) and cephalometric surgical prediction (TPQ) initial. She was decompensated and prepared for the orthognathic surgery. Surgical phase: maxillary advancement and impaction, mandibular retroposition and aesthetics of the upper lip. Postsurgical stage: consolidation and stabilization of the case. Occlusal stabilization and retention. The results were satisfactory, improving the facial features.INTRODUCTION
Cleft lip and palate (CLP) is one of the most common congenital malformations and is caused by a failure in the fusion of the tissues that will give rise to the upper lip and palate. During embryonic development, the primitive mouth begins its formation between 28 and 30 days of gestation with the migration of cells from the neural crest to the anterior region of the face. Between the fifth and sixth week the frontonasal and mandibular processes derived from the first pharyngeal arch form the primitive mouth. Subsequently the palatal processes fuse with the median nasal septum to form the palate and uvula between 50 and 60 days of embryonic development.1
Lip-palatal fissures are the result of non-union of the central and lateral processes of the face during embryonic development. They can occur on the lip or palate or in combination and their cause is multifactorial. However, this type of alteration not only affects the physical appearance of the face, but also involves problems with feeding, dentition, hearing, language, self-esteem and self-image, as well as upper and lower respiratory diseases.2
The areas affected by facial clefts are usually the upper lip, alveolar ridge, hard palate and soft palate. Slightly more than 50% are combined clefts of the lip and palate and about a quarter of them are bilateral. The frequencies given for these malformations are variable among populations, ranging from 1 in 500 births in Asians, to 1 in 2,500 in afro-descendants and 1 in 1,000 among Caucasians, Hispanics and Latin Americans. In Mexico, the incidence is about 1.1 to 1.39 per 1,000 registered live births.3
The origin of CLP is multifactorial, and can be divided into genetic and environmental factors. Environmental causes can be grouped into three classes: physical, chemical and biological. By modifying embryological development and producing deformations, environmental factors have been called teratogens. Research on risk factors for CLP has shown, for example, that the frequency of children with such anomalies is more common in epileptic mothers who take anticonvulsants during the first trimester of pregnancy. They have been linked to acute illnesses, especially influenza.3 Several studies have concluded that this type of anomaly is probably due to drug or other drug interaction, alcohol consumption, maternal smoking, maternal age, diabetes in pregnancy, previous miscarriages, genetic and nutritional aspects, pesticide use in agriculture, ionising radiation, infectious agents, stress, family history and the presence of other craniofacial malformation.3
Clefts of the lip are more common in males, while isolated clefts of the palate are more common in females. The incidence of cleft lip is more common on the left side than on the right.3
The incidence of cleft lip and palate in Mexico, according to Armendares and Lisker (2003), is reported to be 1.39 cases per 1,000 live births.4 González-Osorio CA conducted a study from 2003 to 2009 and presented 10,573 new cases of CLP (average of 1,510.43 per year). The states with the highest rate of CLP (× 1,000 births) were in 2003 Mexico City (1.76), in 2004 Jalisco (2.62), in 2005 Oaxaca (1.66), in 2006 State of Mexico (1.29), in 2007, 2008 and 2009 Jalisco (2.17, 2.92 and 1.99, respectively). Males were the most affected (p < 0.05).3
In the mid-1990s, the Orthodontic Service of the National Institute of Paediatrics implemented early orthopaedic treatment of patients with cleft lip and palate, based on the concepts of functional matrix and the principles of facial growth and development. Due to the observation and follow-up of patients, the current management of three-dimensional and soft tissue orthopaedics was developed, which induce adequate facial growth and improved psychosocial development.5
Before developing the concepts and techniques underlying the current philosophy of orthopaedic treatment of CLP patients, we briefly review the background that gave rise to it. In 1880, Kingsley reported the treatment of patients with CLP, but it was not until after the Second World War that the school of functional orthopaedics of the jaws was consolidated in Europe under the principles described by Roux, referring to functional adaptation, giving rise to a number of facial growth reshaping devices.5
During the 1960s, Moss presented his theory of the functional matrix, which stimulated innumerable services to present their experiences, among others, the work of Bjork and Broadbent. In the 1970s, Enlow published his work on growth and facial development based on the principle of parts and counterparts. These principles, in the case of bilateral clefts, gave rise to the first recognised pre-surgical orthopaedic treatment, with attempts at retropositioning the premaxilla induced by forces from a traction spring adapted to a cap, or by means of an apparatus called a moustache, which followed the principles of the extraoral arch, where the aim was to bring the premaxilla into a posterior position until it made contact with the lateral segments, or rather, repositioned between them. The result of these treatment mechanics was maxillary retrusion in the majority of cases, which meant that facial masks had to be used in later stages of growth to traction the maxilla. Another situation to consider was that, on many occasions, the premaxilla did not move back into the body, producing only an anomalous inclination.5
It is known that there is a deformation of the nasal cartilages due to poor muscle insertions and lack of support in the nasal floor. Facial growth tends to be complex, with no single structure functioning in isolation. Therefore, to achieve an excellent result in facial aesthetics, the soft tissues have to be rehabilitated, which is achieved with myofunctional appliances. It should be emphasised that the treatment of patients with CLP requires a comprehensive, multidisciplinary and interdisciplinary approach and that, thanks to the daily application of these concepts, with individualised discussion for each patient, the results currently achieved are very satisfactory, both functional and aesthetic.5
The usual surgical procedures can be more than 15 in each case, such as cheiloplasty, vomerian flap, primary nasal tip plasty, myringotomy, palatoplasty, pharyngoplasty, retropharyngeal flap, fistula closure, cul-de-sac plasty, osteotomies, surgical orthodontics, alveolar bone grafting, secondary rhinoseptumplasty, dental implants and other secondary corrections. Many of these are combined in a single surgical procedure. In the first surgical stage, after preoperative orthopaedics, comprehensive treatment of the primary palate is usually performed with procedures such as primary cheilonasoplasty, vomerian flap or nasal floor treatment and myringotomy. Depending on the phenotypic variables and the surgeon's preferred approach, in the second stage, procedures are usually performed such as palatoplasty and occasionally closure of anterior fistulas or alveolar plasty, revision of the upper lip pouch and possible touch-up of the first surgery, either on the lip or nose. As a third stage, in general, after assessing the growth and development of the structures of the middle third of the face, the development and evolution of language, the programme is formalised to correct possible secondary velopharyngeal insufficiency and stabilise the dental arch, either with mucoperiosteal union of the alveolus, or with alveolar bone grafting. A possible fourth stage is often devoted to secondary rhinoseptumplasty, various ostotomies, or minor secondary corrections.4
Muscle function may be reduced due to the opening of the roof of the mouth and lip, resulting in delayed or abnormal speech. It is a disorder that can cause pneumonias. Due to the close relationship between the internal orifice of the eustachian tube and the oropharynx in the case of cleft lips with cleft palate, middle ear infections occur frequently. The mechanical factor is the irritation caused by food easily coming into contact with the pharyngeal orifice of the eustachian tube, resulting in inflammation that closes the lumen of the duct and facilitates infection. It has been observed that most of these patients with complete cleft lip and cleft palate have a hearing loss of more than 10 decibels, which seems to increase as the age at which the reconstruction of the anterior and posterior palate is performed increases. This is why it is necessary to treat these patients as early as possible.6
Sometimes an operation at an early age, such as surgical closure of the hard palate, causes fibrosis during healing, preventing normal development of the upper jaw, producing an Angle class III occlusion and developing a pseudoprognathism profile.7-9
CLINICAL CASE
23-year-old female patient, with sequelae of cleft lip and palate. Class III dentoskeletal, dolichofacial, hyperdivergent growth, concave profile, canted occlusal plane, mandibular laterognasia, anterior and posterior crossbite, oronasal communication at the level of the left upper canine, right side with class I molar and class I canine, left side class I molar, class I molar, class canine not assessable (Figures 1 and 2).
In the pre-surgical phase Roth 0.022" system was placed, extractions of dental organs 12 and 22 were performed, VTO and initial TPQ. She was decompensated and prepared for orthognathic surgery (Figures 3 and 4).
In the surgical phase maxillary advancement and impaction, mandibular retroposition and upper lip aesthetics were done (Figure 5).
Postsurgical phase consisted in consolidation and stabilisation of the case, as well as occlusal settling and retention.
Satisfactory dentoskeletal results were obtained, improving facial characteristics (Figures 6, 7, 8 and 9).
DISCUSSION
The treatment is complex and requires a multidisciplinary team of professionals to achieve facial, dental and neuromuscular harmony. In some cases, it is necessary to place an alveolar bone graft to definitively stabilise the alveolar arch. In this case it was performed during childhood and when orthognathic surgery was performed, adequate healing was observed.
The main motivation of patients with cleft lip and palate is not only to restore masticatory function but also to have better aesthetics. Considering that this malformation causes cosmetic, phonetic, auditory, malocclusion, dental anomalies and absences, transverse collapse of the maxilla, emotional and psychological problems, surgical intervention is necessary for its correction. The objectives considered at the beginning of the treatment were met, especially the facial balance which was of vital importance for the patient, achieving a successful treatment.
CONCLUSIONS
It is very important to carry out a detailed diagnosis in order to determine the appropriate treatment for each patient and to be able to meet their expectations, always leaving an adequate dental function in harmony with their facial aesthetics.
In many cases an interdisciplinary relationship with other dental specialties is necessary to achieve a successful treatment.
REFERENCES
González-Osorio CA, Medina-Solís CE, Pontigo-Loyola AP, Casanova-Rosado JF, Escoffié-Ramírez M, Corona-Tabares MG. Estudio ecológico en México (2003-2009) sobre labio y/o paladar hendido y factores sociodemográficos, socioeconómicos y de contaminación asociados. An Pediatr (Barc). 2011; 74 (6): 377-387.
AFFILIATIONS
1 Especialista en Ortodoncia y Ortopedia.
2 Académico en la División de Estudios de Posgrado e Investigación (DEPeI) de la UNAM. México.
3 Especialista en Cirugía Maxilofacial. Académico en la DEPeI de la UNAM. México.
4 Especialista en Cirugía Maxilofacial.
5 Especialista en Prótesis Bucal e Implantología.
6 Especialista en Periodoncia e Implantología.
CORRESPONDENCE
Ana Rosa García Salinas. E-mail: anarosags2010@hotmail.comReceived: Agosto 2020. Accepted: Noviembre 2020.