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Takashi S. Kajii, DDS, PhD1

Mohammad K. Alam,

DDS2

Junichiro Iida, DDS, PhD3

ORTHODONTIC TREATMENT OF CLEFT

LIP AND ALVEOLUS USING SECONDARY
AUTOGENOUS CANCELLOUS BONE
GRAFTING: A CASE REPORT
Aim: This paper concerns orthodontic alignment of the maxillary lateral 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 satisfactory 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 positioning 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.

1Assistant

Professor, Department of
Orthodontics, Graduate School of
Dental Medicine, Hokkaido University, Sapporo, Japan.
2Graduate Student, Department of
Orthodontics, Graduate School of
Dental Medicine, Hokkaido University, Sapporo, Japan.
3Professor and Chair, Department of
Orthodontics, Graduate School of
Dental Medicine, Hokkaido University, 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: kajii@den.hokudai.ac.jp

left 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 III malocclusion,
although not generally severe. Malformed 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 routine procedure for the treatment of cleft
lip and alveolus (and palate) cases. Secondary 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 performed at the early stage of mixed dentition. The newly grafted bone 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 autogenous 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.
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Fig 1

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

At the age of 6 months, she underwent

cheiloplasty using a modified Millard technique at the Plastic Surgery of Hokkaido
University Hospital, Sapporo, Japan. Her
main complaint was esthetic: an anterior
crossbite. No speech disorder, temporomandibular disorder symptoms, or any
other significant medical history was
observed.
The patient presented a symmetrical
face with a concave profile showing functional anterior protrusion of the mandible
(Fig 1) due to premature contact between
the maxillary and mandibular central
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 periapical projection revealed an alveolar cleft
on the maxillary left side and a pegshaped maxillary left lateral incisor. Lateral cephalometric analysis showed a
skeletal Class I type, a slightly high angle
facial configuration, as well as lingual inclination of the maxillary incisor (Table 1).
The patient was therefore diagnosed
as Angle Class III, skeletal Class I malocclusion with functional anterior protrusion of the mandible.

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

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Fig 3 (a) Pretreatment (9 years 7

months), (b) pretreatment without
functional anterior position of
mandible, and (c) midtreatment
(14 years 7 months) radiographs.

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 crossbite, as well as a posterior bite plate on
the mandibular arch to eliminate any
interference between the incisors. Secondary autogenous cancellous bone graft
of the alveolar ridge was then planed
before eruption of the maxillary left lateral 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 discontinued, followed by placement of a new lingual 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 diagnosed 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

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Fig 4

Kajii et al

Orthodontic correction.

Table 1

Cephalometric measurements

SNA (degrees)
SNB (degrees)
ANB (degrees)
FMIA (mm)
IMPA (mm)
FMA (mm)
FH to occlusal (degrees)
U1-SN (degrees)
Interincisal angle (degrees)

Pretreatment
9 y 7 mo

Interim
14 y 7 mo

Posttreatment
18 y 4 mo

2 y after debond
20 y 8 mo

80.0
77.2
2.8
57.8
89.9
32.3
14.2
84.7
146.9

81.0
77.5
3.5
57.6
88.7
33.7
9.6
104.9
126.2

81.0
77.8
3.1
54.6
92.1
33.3
10.2
107.9
120.5

81.0
77.9
3.1
53.1
93.6
33.3
11.0
104.7
122.4

to placing a fixed edgewise appliance, a

distalizing zig was inserted on the maxillar y right side (Fig 4). The zig was
removed, followed by placement of a
fixed edgewise appliance (0.022
0.028 in, preadjusted). During the leveling period, the maxillary left lateral
incisor was brought to the line of occlusion 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 mandibular
arches, respectively. To maintain overbite, 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 radiography and periapical projection after
treatment showed no root resorption
(Figs 7 and 8). During treatment, the
patient showed no temporomandibular
disorder symptoms. The lef t 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 maintained (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 satisfactory if the patient had presented with
a palatal cleft in addition to the alveolar
cleft.
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Fig 5

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

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 clef t side was
reversed: at 12 years of age, bone grafting 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 bridgework in the space would have been
required, unless the need for bone grafting had been obviated due to a considerably 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 maintained for a longer period of time.11,13,14
In the present subject, however, displacement of the lateral incisor root using
orthodontic force was necessary. Failure
to maintain the grafted bone was possibly 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

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b
Fig 6

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

(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 stability of the grafted bone.

ACKNOWLEDGMENTS
The authors would like to thank Associate Prof
Yoshiaki Sato (Depar tment of Or thodontics,
Hokkaido University), Dr Kunihiro Kawashima (plastic surgery, Sapporo City Hospital), and Dr Hiroharu
Igawa for their contributions to this report.

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

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

Pretreatment
Interim
Posttreatment
2 y after debond

Fig 9

Cephalometric superimposition.

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