1Department of Oral and Maxillofacial Surgery, ITS Dental College, Ghaziabad, India
Corresponding author details:
Pallavi Srivastava, Sr. Lecturer
Department of Oral and Maxillofacial Surgery
ITS Dental College
Ghaziabad,India
Copyright: © 2020 Srivastava P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 international License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Cleft lip and/or palate constitute a large fraction of all human birth defects and has a reported incidence of 3.7 per 1000 live births respectively. Embryologically the formation of tooth germs and occurrence of cleft and/or palate defects have a close relationship both in terms of timing and anatomical position of odontogenic epithelium over premaxillary and mandibular process. In some bilateral cleft lip/palate patients the premaxilla is severely protruded and twisted; cleft becomes very wide and unmanageable. In such a situation, osteotomy of the premaxilla to set it back between lateral segments is useful. Many auxillary devices have been used for the fixation of the osteotomized premaxilla such as occlusal splints and direct interdental wiring between the premaxillary central incisors and the teeth adjacent to the alveolar cleft margins, Cementing a bite splint, arch bar and orthodontic brackets can also be used for this purpose. Many clinicians have confronted inadequate posteriorly positioned premaxilla, as it is not stable and has noticeable movements. Tipping of the premaxillary segment is the other problem. As described by Carlini et al, the miniplate has been applied for fixation of osteotomized premaxilla to the lateral segments.
Cleft Lip and Palate; Premaxilla; Osteotomy
The bilateral cleft of lip, alveolus and palate is generally considered as the most severe
congenital deformity of the upper jaw and the central part of the face. Its surgical correction
is difficult and the results achieved are often not satisfying in regard to aesthetic and function
[1]. An important aspect of the BCLP patient is that the alveolar clefts cause the premaxilla
to be mobile from birth and only apically fixed to the vomer bone. The premaxilla is often
protruding due to the lack of sphincter function of the orbicularis oris muscle. This causes
extreme abnormalities in the position of the premaxilla; sometimes, the whole segment is
rotated and functional and cosmetic disorders result [2]. Many studies have been conducted
to evaluate the efficacy of alveolar bone reconstruction for alveolar cleft patients performed
with the traditional iliac graft or alternative/supplementary bone grafting materials [3].
This case report describes a patient with bilateral cleft palate which is reconstructed using
iliac bone graft and retained using 2mm miniplate [4] hole with gap bilaterally
A 19 years old female patient with the history of repaired cleft lip twice at the age
of 6 months and 1 years of age respectively. The patient now is more concerned of her
aesthetic because of her fowardly placed central incisors for which she reported to our
department. On extra oral examination the middle and lower 1/3rd of the face showed
bilateral asymmetry with Broad nasal bridge and the dorsum, Depressed or ill-defined
nasal tip projection, Deviated tip of the nose towards the left side and Flaring of the ala of
the nose [5-8]. The lower 1/3rd of the face shows massive scar over the philtrum due to
previous surgical approach with loss of cupid bow on upper lip, Incompetent lips (short
upper lip), forwardly placed maxillary incisors (incisor show), mismatched White roll,
Ille defined philtrum with absence of philtrum ridges (Figure 1). Intraoral examination
showed high arch palate, collapsed maxillary ridges and protruded premaxillary segment
with overlapped maxillary central incisors (Figure 2). The maxillary occlusal radiograph
confirmed bilateral cleft palate with the stalk like attachment of the premaxilla with the
vomer bone (Figure 3).
Figure 1: Extraoral profile view
Figure 2: Intraoral view
Figure 3: Occlusal radiograph
The treatment plan was surgical setback of premaxillary segment followed by secondary alveolar bone grafting with cortico cancellous particulate
iliac bone graft under general anesthesia. The patient was painted
and draped under aseptic condition. A vestibular incision was given
in the upper labial vestibule to expose the premaxillary segment
(Figure 4). The osteotomy and setback of premaxillary segment
was performed and miniplates were placed to secure the mobile
premaxillary segment with the lateral maxillary segments bilaterally.
Simultaneous exposure of right iliac bone was done to harvest the corticocancellous bone with the help of trephine (Figure 5). The
particulate bone was condensed and packed at the alveolar cleft
defect and the labial vestibule was sutured around the alveolar cleft
with 5-0 vicryl sutures and layer by layer closure was performed at
the donour site with 2-0 vicryl (Ethicon) (Figure 6). Intraoperatively
the K-wire was splinted on anterior teeth to give additional support
and alignment to the anterior teeth (Figure 7). Up to 2 months of
follow up and sequential radiographs patient showed good amount of
bone at the cleft site with improved facial profile with no associated
complications (Figure 8).
Figure 4: Intra-Operative procedure of premaxillary setback and
miniplate fixation
Figure 5: Intraoperative iliac bone harvesting procedure
Figure 6: Intraoperative pictures showing particulate bone graft
condensed at the cleft site and closure of the operative site
Figure 7: Picture showing placement of k-wire for the alignment
of teeth
Figure 8: 1 Week and 1 month follow up respectively
The presence of bilateral cleft lip and palate often results in
protruded premaxillary segment in these patients which increases
the risk of trauma and compromises the functions such as speech,
mastication, swallowing and also pose psychologic impact on
the patients due to altered facial profile [9-11]. An orthodontic
intervention at appropriate time helps to expand the posterior
maxillary segments which provides sufficient space for the setback
of the premaxilla and also sustains the blood supply. Several studies
have reported the long term complications in the cleft patients such
as impaired midfacial growth, maxillary retrusion, and concave facial
profile, class III relationship leading to mandibular prognathism and
tipping of the premaxilla [12-14]. This technique used for the setback
of the osteotomised premaxilla provides additional three dimensional
supports to the mobile segment along with the use of splinting wire
that helps to align the anterior teeth. The use of this technique also
gives support to the densely packed particulate bone graft and thus
eliminates the chance of fistula formation and requirement of second
surgical intervention (Figure 9).
Figure 9: preoperative and postoperative profile view
In protruding premaxilla, osteotomy and fixation of premaxilla
with a miniplate to the bone lateral to the cleft and alveolar bone
grafting approach has satisfactory outcomes in patients who require
secondary functional palate repair
Copyright © 2020 Boffin Access Limited.