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CASE REPORT

Early orthodontic intervention followed by xed appliance therapy in a patient with a severe Class III malocclusion and cleft lip and palate
He Zhang,a Feng Deng,b Huaqiao Wang,a Qianqian Huang,a and Yi Zhangc Chongqing, China

This case report describes the treatment of a girl, age 11 years 10 months, with a cleft lip and palate and a postsurgical scar. The clinical examination showed a concave prole, a retrusive maxilla, an asymmetric face, severe dental crowding, a Class III dental relationship, and a complete dental crossbite. Maxillary expansion and distraction, chincap, and high-pull headgear were used to moderate the skeletal discrepancy. These approaches, combined with tooth extraction and xed orthodontic appliances, nally established a functional and esthetic occlusal relationship, normal overjet and overbite, and a well-balanced facial appearance. (Am J Orthod Dentofacial Orthop 2013;144:726-36)

skeletal Class III malocclusion has been acknowledged to be the most challenging problem confronting orthodontists, especially when it is associated with cleft lip and palate.1 Primarily because of the unpredictable and potentially abnormal growth in patients with this skeletal pattern, treatment planning for most young patients with Class III malocclusion has been directed at growth modication.2 Although early treatment of these patients commonly achieves a relatively more normal jaw relationship, there have been few case reports of early intervention for a Class III malocclusion in a patient with cleft lip and palate.3 Most patients with cleft lip and palate have altered and decient maxillary growth as a result of postsurgical scar contraction or anatomic anomalies, and even may have dental arch deformities. Our aims of orthodontic treatment for these patients are to solve or moderate

these deformities and to establish an ideal maxillomandibular relationship.4 This case report describes the treatment of a girl, age 11 years 10 months, with cleft lip and palate and a postsurgical scar, a Class III malocclusion, maxillary anterior crowding, and a complete dental crossbite.

DIAGNOSIS AND ETIOLOGY

From the Afliated Hospital of Stomatology, Chongqing Research Center for Oral Diseases and Biomedical Science, Chongqing Medical University, Chongqing, China. a Staff orthodontist. b Professor and hospital director. c Director, Department of Orthodontics. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported. Address correspondence to: Yi Zhang, Department of Orthodontics, Afliated Hospital of Stomatology, Chongqing Medical University, Chongqing Research Center for Oral Diseases and Biomedical Science, 5 Shangqingsi Rd, Yuzhong District, Chongqing 400015, P. R. China; e-mail, zhangyi.dentist@hotmail.com. Submitted, April 2012; revised and accepted, November 2012. 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2012.11.028

The girl and her parents came for orthodontic treatment with chief complaints of a crossbite and an unesthetic smile. She had received surgery at the age of 4 years and had no contraindication to orthodontic therapy. The pretreatment examination (Fig 1) and the dental casts (Fig 2) showed a concave prole (suggesting maxillary retrusion) and an asymmetric face (suggesting mandibular deviation). There was severe dental crowding (13 mm), and a left deciduous second molar remained in the maxilla; in the mandible, the deciduous second molars remained on both sides, with mild dental crowding. She had a Class III dental relationship on the left side and a Class I relationship on the right, as well as a complete dental crossbite. The maxillary midline deviated 3 mm to the right from the facial midline, and the mandibular midline was shifted 1 mm to the left. The cephalometric tracing (Fig 3) and analysis (Table) showed a vertical skeletal pattern (MP-FH, 34 ; PFH, 64.1 ; AFH, 105.1 ; FHI, 0.6) and a Class III skeletal relationship with maxillary retrusion (SNA, 81.2 ; SNB, 84.1 ; ANB, 2.9 ). The mandibular incisors were retroclined (IMPA, 77.5 ; 1.NB, 20 ; 1-NB, 3.8 mm). The concave

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Fig 1. Pretreatment photographs.

Fig 2. Pretreatment dental casts.

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Fig 3. Pretreatment cephalogram and tracing.

Table. Cephalometric analysis


2 years after treatment 82.3 82.2 0.1 3.8 38.3 133.4 44.8 14.9 85.7 69.8 113.3 0.6 66.9 111.1 134.7 65.8 75.9 18.8 3.6 27.2 6.4 69.9 89 3.1 2.4

Measurement Skeletal SNA ( ) SNB ( ) ANB ( ) Convexity ( ) MP-FH ( ) Gonial angle ( ) SL (mm) SE (mm) NP-FH ( ) PFH (mm) AFH (mm) FHI (PFH/AFH) Y-axis ( ) Dental U1-FH ( ) U1-L1 ( ) FMIA ( ) IMPA ( ) 1.NB ( ) 1-NB (mm) 1.NA ( ) 1-NA (mm) Soft tissues Z-angle ( ) Nasolabial angle ( ) ULP (mm) LLP (mm)

Average 82.3 6 3.5 78.9 6 3.5 3.4 6 1.8 1.6 6 4.8 28.8 6 5.2 131.0 6 5.6 41.9 6 6.2 20.6 6 2.7 88.6 6 3.2 45.0 64.0 0.7 65.4 6 5.6 111.1 6 5.5 120.3 6 10.1 54.6 6 6.5 96.3 6 5.8 31.0 6 6.6 7.8 6 2.4 24.7 6 5.2 6.2 6 1.9 69.11 6 4.74 100 2.5 6 1.5 2.6 6 1.5

Initial 79.8 83.6 3.8 7.3 33.9 133.6 45.5 15.7 89.4 63.2 105.4 0.6 61.4 115 133.8 66.7 79.4 23 5.1 30.7 6 80.5 95 2.7 2.5

Final 82.1 82.8 0.7 3.5 37.2 133.7 45.3 14.5 86 69.9 111.5 0.6 66.5 112.9 129.3 64.4 78.4 20.6 4 27 6.4 70.3 93 4.0 1.7

Fig 4. Pretreatment panoramic radiograph. TREATMENT OBJECTIVES

Since this patient had a cleft lip and palate with a Class III malocclusion and a vertical skeletal pattern, the realistic and ideal treatment objectives were to (1) correct the maxillomandibular skeletal discrepancy; (2) obtain a normalized, functional, and stable occlusion; (3) create satisfactory overbite and overjet; (4) align the maxillary and mandibular dentitions and correct the midline; and (5) improve the dental esthetics and provide a favorable facial prole.
TREATMENT ALTERNATIVES

prole was due to a sagittally decient maxilla (Z-angle, 79.6 ; ULP, 2.8 mm; lower lip-E plane [LLP], 2.4 mm; nasolabial angle, 96 ). Both the left and right second premolars were developing and could be seen on the panoramic radiograph (Fig 4). The right mandibular ramus length was slightly shorter than that of the left side.

All alternatives made during the diagnosis were presented to the patient and her parents. Because she still had some maxillomandibular growth potential to accomplish ideal treatment goals, a nonsurgical approach was considered to be the best treatment option. For an 11-year-old girl with cleft lip and palate, xed orthodontic appliances alone had limitations, and the assistance of some other dental specialties was required to camouage certain skeletal and dental factors of her

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Fig 5. Treatment progress: A, maxillary expansion, with a jackscrew expansion appliance; B, construction used for protraction; C, 5 months after maxillary expansion and protraction.

malocclusion and to help improve esthetics and function. The options considered included (1) maxillary and mandibular rst premolar extractions, compensation mechanics, and further occlusal adjustment with Class III elastics; (2) rapid maxillary expansion and distraction as well as a high-pull chincap to moderate or correct the Class III skeletal relationship, with extraction of the maxillary and mandibular rst premolars to correct the crowding, overjet, and anterior crossbite; and (3) combined therapy of orthodontic-orthognathic surgery after she reached 18 years old.
TREATMENT PROGRESS

Treatment began with maxillary expansion using a jackscrew expansion appliance soldered to 2 banded teeth per side (Fig 5, A). The appliance was activated at a rate of 0.5 mm per day for 15 days, until the posterior crossbite had been moderated. The facemask and the construction used for protraction were connected with anterior hooks in the canine region for elastics (Fig 5, B). A 400-g to 500-g protraction force was transferred to the hooks per side, with the elastics adjusted to provide a forward and downward

pull at 30 to the occlusal plane to minimize the side effect of counterclockwise rotation. The patient wore the facemask for at least 12 hours a day, and it was started after 4 weeks of maxillary expansion. The anterior crossbite was corrected 3 months later (Fig 5, C). The transverse expansion and protraction of the maxilla was maintained for 5 months to limit the relapse caused by the scar contraction and the increased muscle tension. A chincap and high-pull headgear were used to limit the excessive mandibular anterior facial height, and TipEdge brackets (TP Orthodontics, La Porte, Ind) were bonded to the teeth (Fig 6). With sequential nickeltitanium archwires, dental alignment and leveling were observed in 3 months. We placed an 0.018 3 0.025-in stainless steel wire and an Australian wire, respectively, in the maxillary and mandibular dental arches. Then nickel-titanium coil springs (Fig 7, A) and Class III elastics (Fig 7, B) were used for space adjustment and distal movement of the mandibular dental arch. Then the Tip-Edge brackets were replaced by preadjusted 0.022-in brackets (MBT; 3M Unitek, Monrovia, Calif). Australian wire and 0.18 3 0.025-in stainless steel archwires were used to align the teeth more precisely. At

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Fig 6. Combination of high-pull chincap and Tip-Edge brackets.

Fig 7. Treatment progress: A, nickel-titanium coil springs for space adjustment; B, Class III elastics for mandibular dental retrusion; C, Tip-Edge brackets replaced by MBT brackets and mini-implant for midline correction.

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the third stage, to correct the maxillary midline, a miniimplant (1.6 3 9 mm; Medicon, Tuttlingen, Germany) was placed between the roots of the maxillary right lateral incisor and canine, 3 mm occlusally to the vestibular groove (Fig 7, C). The treatment lasted 3 years 2 months. It took over 12 months to establish Class I molar relationships, including maxillary expansion, protraction, and tooth movement, and 6 months to correct the midline.
TREATMENT RESULTS

The posttreatment facial photographs (Fig 8) and dental casts (Fig 9) indicated a noteworthy improvement in the lower facial prole from the pronounced retraction of the mandibular anterior teeth. The lower lip moved backward, shown by LLP, resulting in an optimized lip relationship. Because of the better mandibular incisor and lower lip positions, the soft-tissue prole became more convex, the Z-angle decreased signicantly, and the nasolabial angle also decreased slightly. Meanwhile, the crossbite had been corrected, and Class I canine and molar relationships were achieved with normal overbite and overjet. The lateral cephalometric tracing and analysis (Fig 10, Table) were consistent with the clinical results. Vertically, lower facial height increased as shown by MP-FH, PFH, and AFH, yet the facial height ratio was maintained. Sagittally, the skeletal discrepancy between the maxilla and the mandible was remarkably moderated, as conrmed by the SNA, SNB, and ANB angles. The mandible tilted down and backward because of the pressure exerted on the chin. Although the treatment for this patient was a compromise, satisfactory results were obtained. In addition, her facial convexity was signicantly improved as shown by NP-FH and y-axis. The mandibular incisors moved backward to a more acceptable position as shown by 1.NB, 1-NB, FMIA, IMPA, and the interincisal angle. The maxillary incisors were also retruded as shown by U1-FH and 1-NA. The soft-tissue prole changes between pretreatment and posttreatment, as well as the skeletal prole improvement and tooth movement, were clearly evident on the superimposition of the cephalometric tracings (Fig 11). It also shows that no change was observed in the position of the condyle relative to basion and the gonial angle; this was conrmed by the cephalometric analysis. The level of interradicular bone was relatively stable after treatment as seen on the panoramic radiograph (Fig 12). There is a bony apophysis appearing obviously along the lower border of the mandible, close to the chin. The treatment plan was a satisfactory nonsurgical alternative, and a functional and esthetic occlusal

relationship was established. The more favorable mandibular incisor inclination resulted in normal overjet and overbite, and a well-balanced facial appearance was achieved. Correction of the malocclusion and improvement of her facial prole were accomplished with both dentoalveolar and skeletal changes. After 2 years of retention, the posttreatment occlusion and anterior overjet continued to be stable (Fig 13). The skeletal (Fig 14) and soft-tissue (Fig 15) facial prole were also satisfactory, and there was no signicant change shown on the panoramic radiograph (Fig 16).
DISCUSSION

Midface retrusion and malocclusion are concerns for patients with operated cleft lip and palate. Because of the possible inuence of cleft severity on the growth of the maxilla, cleft lip and palate patients can have a relatively retruded maxillary position with a tendency for a Class III malocclusion, even after palatoplasty.1,5,6 The tension of the scar contraction resulting from the palatal repair could adversely affect maxillary growth. Most cleft lip and palate patients require a LeFort I osteotomy after completion of skeletal growth to reposition the maxilla. This type of surgery might also require rigid xation, bone grafting, and mandibular setback.6,7 However, these treatments are quite invasive. Maxillary expansion and distraction osteogenesis are considered an attractive alternative to correct the malocclusion in cleft lip and palate patients,6,8,9 although a chincap and high-pull headgear have also been advocated in the treatment of Class III malocclusion.10 Labial tipping of the maxillary incisors could not be avoided because the maxillary anterior teeth were used as an anchor for the distraction forces. Because of the rst premolar extraction, proclination of the maxillary anterior teeth had been slightly decreased. The pronounced improvement of the patients facial prole and occlusal relationship suggested that orthognathic surgery was unnecessary for correcting her skeletal discrepancies. In addition, because of her unesthetic facial appearance and unattractive smile, the patient and her parents did not want to wait another 10 years to have surgical treatment. Also, the malocclusion could have become worse with time if it were not corrected. Therefore, orthognathic surgery was nally abandoned after careful consideration. The esthetic improvement obtained in this cleft lip and palate patient was impressive as a result of favorable maxillary advancement and mandibular incisor retrusion, which were achieved by maxillary protraction, mandibular growth inhibition, and premolar extraction.

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Fig 8. Posttreatment photographs.

Fig 9. Posttreatment dental casts.

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Fig 10. Posttreatment cephalogram and tracing.

Fig 12. Posttreatment panoramic radiograph.

Fig 11. Superimposed tracings. Blue lines, pretreatment tracing; red lines, posttreatment tracing.

Early intervention by protracting the maxilla was intentionally controlled. One side effect of facemask protraction is unexpected proclination of the maxillary anterior teeth; this would cause undesirable prole changes (concave facial prole with maxillary incisor proclination). Hence, premolar extraction was necessary to keep her maxillary incisors upright. Although most Class III patients have retroclined anterior mandibular teeth, retraction of the mandibular incisors still helps to deepen the labiomental fold, which is at in most Class III patients. This further contributes to the improvement of the facial prole. Our results are similar to those of Lin

and Gu,11 who suggested that by treating Class III patients with compensatory mechanics, remarkable soft-tissue changes can be observed when the facial prole changes from concave to straight.12 However, other factors such as the patients age, skeletal growth pattern, individual growth potential, and cooperation are also important in producing the entire treatment effect.13 The age of the skull is an essential element that affects the mechanical property of the skeletal suture.14,15 So, timing is crucial to achieve successful orthodontic treatment. Beginning treatment at the correct time in a patient with growth potential has a signicant inuence on correcting the discrepancy in the sagittal, vertical, and transverse planes. It is recommended that treatment directed at promoting or inhibiting maxillary or mandibular growth should be performed before the pubertal growth spurt.16 Normally, midface growth up to the age of 7 years is attributed to the increasing size of the anterior cranial base, orbits, and nasal septum. All facial bones move forward and downward from growth of the synchondroses.17 However, normal

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Fig 13. Photographs 2 years after treatment.

Fig 14. Cephalogram and tracing 2 years after treatment.

forward and downward growth was not expected because of the underdeveloped maxilla, especially in this patient with cleft lip and palate. Consequently,

expansion and protraction therapy was considered for her. But the space provided by the rapid maxillary expansion was not enough to correct the dental crowding;

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morphologic changes have been rarely reported. Although similar bone apophysis might also be observed in other clinical cases in which the chincap was used, further study related to its mechanical properties should be conducted. The posttreatment results show good stability after more than 2 years. The prevention of posterior and anterior crossbite by maxillary expansion and distraction, and the long-term chin growth inhibition with the chincup seemed to contribute to this stability.
CONCLUSIONS

Fig 15. Superimposed tracings of posttreatment and 2 years after treatment. Red lines, posttreatment tracing; black lines, 2 years posttreatment tracing.

A denitive analysis and treatment plan should be made for each patient. In those with cleft lip and palate who are undergoing a growth spurt, orthodontic treatment objectives should be restoratively realistic, economical, and low risk. In this case report, the nal occlusion was esthetic, functional, healthy, and stable. The early orthodontic intervention combined with the second phase of treatment (xed orthodontic appliances) efciently achieved a satisfactory result, and the patient beneted by gaining self-esteem and improved esthetics.
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Fig 16. Panoramic radiograph 2 years after treatment.

therefore, tooth extraction was a reasonable solution. Luckily, the patients cleft deformity was not unilateral. Thus, the risk of a nonaverage distribution of heavy orthodontic force caused by the asymmetric structure of the skull was greatly reduced.14 Chincap, high-pull headgear, and maxillary protraction appliances have been reported to achieve favorable changes in patients with Class III malocclusion.13,18 Yet whether it is possible to alter the congenital growth pattern signicantly and permanently requires further investigation.13 Interestingly, the apophysis along the lower border of the mandible shown in the posttreament prole was not found on the cephalometric tracing before the chincap was applied. The effects of the chincap were more concentrated on backward repositioning of the mandible, the direction and inhibition of mandibular growth, and the stress distributions on the condyle.19 Remodeling of the mandibular shape and

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Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111: 688-92. Gautam P, Valiathan A, Adhikari R. Stress and displacement patterns in the craniofacial skeleton with rapid maxillary expansion: a nite element method study. Am J Orthod Dentofacial Orthop 2007;132:5.e1-5.e11. Lin J, Gu Y. Preliminary investigation of nonsurgical treatment of severe skeletal Class III malocclusion in the permanent dentition. Angle Orthod 2003;73:401-10. Maruo H, Maruo IT, Saga AY, Camargo ES, Guariza Filho O, Tanaka OM. Orthodontic-prosthetic treatment of an adult with a severe Class III malocclusion. Am J Orthod Dentofacial Orthop 2010;138:820-8. Shanker S, Ngan P, Wade D, Beck M, Yu C, H agg U, et al. Cephalometric A point changes during and after maxillary protraction and expansion. Am J Orthod Dentofacial Orthop 1996;110:423-30. Wang D, Cheng L, Wang C, Qian Y, Pan X. Biomechanical analysis of rapid maxillary expansion in the UCLP patient. Med Eng Phys 2009;31:409-17.

15. Henderson JH, Longaker MT, Carter DR. Sutural bone deposition rate and strain magnitude during cranial development. Bone 2004;34:271-80. 16. Franchi L, Baccetti T, De Toffol L, Polimeni A, Cozza P. Phases of the dentition for the assessment of skeletal maturity: a diagnostic performance study. Am J Orthod Dentofacial Orthop 2008;133:395-400. 17. Sade Hoefert C, Bacher M, Herberts T, Kimmel M, Reinert S, Goz G. 3D soft tissue changes in facial morphology in patients with cleft lip and palate and class III malocclusion under therapy with rapid maxillary expansion and delaire facemask. J Orofac Orthop 2010; 71:136-51. 18. Liu ZP, Li CJ, Hu HK, Chen JW, Li F, Zou SJ. Efcacy of short-term chincup therapy for mandibular growth retardation in Class III malocclusion. Angle Orthod 2011;81:162-8. 19. Tanne K, Tanaka E, Sakuda M. Stress distribution in the temporomandibular joint produced by orthopedic chincup forces applied in varying directions: a three-dimensional analytic approach with the nite element method. Am J Orthod Dentofacial Orthop 1996;110: 502-7.

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