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Multidisciplinary approach for cleftalveolus and impacted canine

Dulal Das1

ABSTRACT:

Any type of aesthetic correction in dental practice is always a

challenging task, especially when it is complicated with cleft

lip and alveolus. Careful examination and correct decision

making at early stage of treatment and multi disciplinary

approach is always necessary for long term success.

This paper describes a multidisciplinary approach in managing

a 19-year-old female patient with unilateral cleft alveolus

impacted maxillary canine, missing lateral incisor and

hypoplastic central incisor by surgical, orthodontic and

prosthodontic means. The impacted canine was surgically

exposed and orthodontic traction given to bring it into the normal

alignment. The missing lateral incisor was replaced by a fixed

bridge with a ceramic gingival fixed prosthesis to manage

alveolar cleft. At the same time the hypoplastic defect of central

incisor was hidden by the full coverage retainer used for the

bridge abutment on the tooth.

Key words: Alveolar Cleft, Gingival Prosthesis, Impacted

Canine, Orthodontic Extrusion

C A S E R E P O R T

doi: 10.5866/2013.531311

1Senior LecturerDept. Of Pedodontics And Preventive Dentistry,Kalinga Institute Of Dental Sciences,Bhubaneswar

Article Info:

Received: April 12, 2013Review Completed: May 11, 2013Accepted: June 10, 2013Available Online: October, 2013 (www.nacd.in)© NAD, 2013 - All rights reserved

Email for correspondence:drdulaldas@gmail.com

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Introduction:.

Cleft patients have markedly higher frequency of congenitally missing and impacted permanent teethas compare to the normal population.1,2 The incidence of congenitally missing permanent lateral incisorswithin the alveolar cleft is between 35 and 60%3 and the frequency of these congenitally missing teeth arehigher in girls than in boys4,5 It is reported by the many researchers that most frequently missing teeth incleft patients are the maxillary lateral incisors in the cleft region and the maxillary second premolars outsidethe cleft region.1

Maxillary canines are the most commonly impacted teeth.6,7 It occurs in approximately 2% of the normalpopulation and is twice as common in females than in males.8,9 Again its incidence in the maxilla is morethan twice that in the mandible.9 Patients with alveolar clefts had a 20-fold increased risk for canine

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impaction.10 In this reported case a comprehensivemultidisciplinary approach was undertaken tomanage a unilateral cleft alveolus with congenitallymissing maxillary lateral incisor and canineimpaction of same side in a 19 years old young girl.

CASE REPORT:

Diagnosis:

A 19 year-old girl was reported in a dental clinicfor the unpleasing smile (Figure-1A)because of herunilateral cleft lip and alveolus of left side of maxillain which surgical correction done 12 years back. Onclinical examination (Figure-2A) it was revealed thatshe had missing maxillary left lateral incisor (22),hypoplastic left central incisor (21) and retainedmaxillary deciduous left canine (63). The clinicalexamination also revealed Angle Class I molarrelationship with deep bite (Figure-2A) andcrowding in lower anterior segment. The permanentleft maxillary canine (23) was not visible in the arch.

The radiological examination (0PG) showed(Figure-1E) that the 23 was impacted, situatedalmost vertically and the crown was directedobliquely mesially into the arch. A clear bony defect(Figure-1F) was observed along the cleft in upperstandard occlusal radiograph.

Treatment:

The objective of treatment was to provide aesthetic profile by preparing an adequate space foran ideal pontic with gingival prosthesis for missing22 with bony defect and proper positioning of theimpacted 23 into the arch to obtain a well alignment.

As because the lower teeth were in crowdingcondition with a stiff curve of spee, so treatmentwas also planned for crowding and deep bitecorrection in the lower dental arch.

After necessary pre surgical investigationsdecision was made to perform orthodontic extrusionof impacted 23 by surgical exploration of the crownof 23. Begs’ brackets were placed in upper and lowerteeth pre-surgically. A full thickness muco-periostealflap was elevated from 21 to24 region under local

anaesthesia, extraction (Figure-3A) of retained 63was done and crown of 23 was discovered just afterremoving a shell of bone from labial cortex. A Begs’orthodontic bracket was placed on 23 and suturingdone (Figure-3B).

As the suture removal done after 7 days,orthodontic traction was started with the help of aE-chain and arch wire (Figure-3C&D). A 0.014mmNiTi wire was used in lower ach for the correctionof crowding. With in 7 months orthodontic extrusionof 23 was completed (Figure-4A) and angulation withvertical axis was corrected by the use of two E-chains(Figure-4B) along the arch in two halves of theedentulous space and by that way sufficient spacewas created for future 22 (pontic). The deep bite wascorrected by incorporating anchorage bend (25°) inlower arch wire. After orthodontic correction ofmalocclusions, all brackets were removed and amodified Howley appliance (removable plate withattached acrilic lateral incisor for to hold the createdspace for 22) was given for six months as a retentivedevice. At the end a removable partial denturereplacing 22 was given to the patient for next sixmonths (Figure-4C) for better tissue adaptation.

At the end of six months vitality testing for 23revealed positive response and an IOPA radiographshowed normal peri radicular area (Figure-1E). Afixed bridge was planned taking 21 and 23 asabutments for missing 22 and a ceramic gingivalreplacement was attached with the pontic foralveolar defect correction (Figure-5A,B,C,&D). Theextracoronal full coverage porcelain fused to metalrestoration on 21 helped to hide the hypoplasticdefect (Figure-2D).

Discussion:

Maxillary permanent canines are important foran attractive smile and are also essential for afunctional occlusion. Offering a pleasing estheticappearance in a patient with cleft lip and alveolusis one of the toughest job in dental practice. Many atimes over retention of deciduous canine makes thesituation more difficult by impacting succedeniouspermanent canine. Surgical exposure of the

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impacted canine and the use of fixed orthodonticappliances is the most frequently used treatmentalternative as long as the tooth position isfavourable. Various methods have been used forbringing the canine into proper alignment. Fournieret al11 have proposed the use of a removable plate.Becker and Zilberman12 have recommended the useof a flexible palatal arch slotted into horizontal,soldered, palatal tubes on the molar bands of anytype of fixed multibonded appliance. Jacoby13 hassuggested his ballista spring to direct a palatal-occlusal force from the buccal side. In this reportedcase the extrusion was done with the help of a E-chain and a arch wire.

Considerable amount of bony defects in anteriorregion can be easily managed by prostheticapproach. A fixed gingival prosthesis (ceramic) orremovable gingival prosthesis (acrylic) can eliminateinvasive surgical procedure.14 A xed prosthesis givesthe patient signicant comfort and peace of mind, aswell as self-condence (because the prosthesis isalways present). However, its application may belimited to certain clinical situations where oralhygiene is manageable, the desired esthetic resultis achievable or esthetics are not critical, and a xedprosthesis is already planned for the immediatearea14. A fixed coral pink coloured ceramic gingivalprosthesis with the pontic replacing the missing 22was planned in this reported case. The bonydeficiency at the alveolar cleft was managed by theceramic gingival prosthesis which was very aesthetc,highly polished and easy to maintain.

The total treatment time was 2 years and postoperative followup was done for another one year.Orthodontic extrusion took almost 7 months whichwas almost one third of the total treatment span.During the treatment step by step correction of deepbite and lower incisors crowding were done inconventional technique.

Conclusion:

Aesthetic correction of a patient with cleft lipand alveolus in is always a challenging job especiallywhen the situation is complicated with over retained

deciduous tooth and impacted permanent tooth. Inthis reported case a combination of Orthodontic,Prosthodontic and Surgical technique wereadvocated to get the ultimate pleasing smile. Onlymultidisciplinary approach and careful evaluationin each an every steps of treatment is mandatoryfor this kind of long term success. As because thecleft patients are belong to very low self esteemedgroup so least invasive treatment modality shouldneed to be advocated for better tolerance.

REFERENCE:

1. Olin WH. Dental anomalies in cleft lip and palate patients.Angle Orthod. 1964;64:119-123.

2. Russell KA, McLeod CE. Canine eruption in patients withcomplete cleft lip and palate. Cleft Palate Craniofac J. 2008Jan;45(1):73-80.

3. Peterson’s Principles of Oral and Maxillofacial Surgery -Volume 1 - Page 861

4. Mattheeuws N, Dermaut L, Martens G. Has hypodontiaincreased in Caucasians during the 20th century? Ametaanalysis. Eur J Orthod. 2004;26:99-103.

5. Brook AH. Variables and criteria in prevalence studies ofdental anomalies of number, form and size. CommunityDentOral Epidemiol. 1975;3:288-293.

6. Ngan P, Hornbrook R, Weaver B (2005) Early timelymanagement of ectopically erupting maxillary canines.Semin Orthod 11:152-163.

7. Bishara SE (1992) Impacted maxillary canines: a review.Am J Orthod Dentofacial Orthop 101: 159-171.

8. Cooke J, Wang HL (2006) Canine impactions: incidence andmanagement. Int J Periodontics Restorative Dent 26: 483-491.

9. Proffit WR, Fields HW, Sarver DM (2007) ContemporaryOrthodontics. (4thedn), St. Louis: Mosby.

10. Yavuz MS, Aras MH, Buyukkurt MC, Tozoglu S (2007)Impacted mandibularcanines. J Contemp Dent Pract 8:78-85.

11. Fournier A, Turcotte JY, Bernard C. Orthodonticconsiderations in the treatment of maxillary impactedcanines. Am J Orthod. 1982;81:236-239.

12. Becker, A, Zilberman Y. A combined fixed-removableapproach to the treatment of impacted maxillary canines.JClin Orthod. 1975;9:162-169.

13. Jacoby H. The ‘ballista spring” system for impactedteeth.Am J Orthod. 1979;75:143-151.

14. Ba rzilay I, Tamblyn I.Gingival Prostheses - A Review. JCan Dent Assoc 2003; 69(2):74-78.

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Figure-1

Proeoperative Intraoperative, AfterOrthodontic Extrussion of 23

Intraoperative, After removableProsthesis for 22

Postoperative, After FixedProsthesis in 22

Preoperative OPG Preoperative Standard Occlusal View Postoperative IOPA Showing 23

Figure-2

Preoperative After Orthodontic Extrusion

Orthodontic Correction Done Fixed Bridge Given for Missing 22 (Postoperative)

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Figure-4

A-Extracting of 63 Done B-Beg’s Brackets Placed in 23

C-Orthodontic Traction Given in 23 D-Partially Erupted 23

Figure-3

Extrided 23 Alignment with 0.014mm NiTiwire with Space Creation for 22

Maintaining space for 22 withone RPD

Well aligned upper cast

Figure-5

Crown Reduction in 21 & 23for FPD

Tooth coloured a crilic resintemporary restoration given in

21 & 23

Metal trial done for FRD Fixed Bride with gingivalprosthesis for missing 22

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Indian J Dent Adv 2013; 5(3): 1311-1315