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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 124-128

Prominent premaxilla management on bilateral cleft lip and palate


1 Department of Orthodontics, Craneofacial Anomalies Foundation at Health Services, Angeles Group, Angeles del Pedregal Hospital, Mexico City, Mexico
2 Department of Clinical Epidemiology, Universidad Nacional Autónoma de Mìxico, Chiapas, Mexico
3 Department of Plastic and Reconstructive Surgery, Hospital de Especialidades Pediatricas, Chiapas, Mexico
4 Smile Train Projet Central America and Caribbean, New York, USA

Date of Web Publication7-Aug-2019

Correspondence Address:
Dr. Tatiana Izchel Castillo Torres
Hospital Angeles Del Pedregal, Office #6, Heroes de Padierna, Mexico City 10700
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_11_19

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  Abstract 

The treatment cleft lip and palate (CLP) should start at an early age with a multidisciplinary team and with a comprehensive approach. The aim of the management of protruded premaxilla in patients with bilateral CLP is to relocate the premaxilla to achieve surgical closure of the lip. The objective of the case report is to present the surgical-orthodontic treatment for the surgical reposition of the protruded premaxilla in a 3-year-old patient with BCLP. A patient of 3 years old with BCLP his treatment plan is a surgical reposition of the premaxilla and posterior closure of the primary lip. The surgical reposition of the premaxilla was made planning the osteotomy with dental casts. After 6 months of starting the surgical-orthodontic treatment, the patient meets bilateral lip closure satisfactorily without reported complications. Planning of the treatment allows performing a procedure that reduces the likelihood of complications and achieving the closing of the lip to reestablish the function, anatomy, and esthetics.

Keywords: Bilateral cleft lip palate, osteotomy, protruded premaxilla reposition


How to cite this article:
Torres TI, Pedrero ML, Dodd JA, Robledo CA, Martìnez MD. Prominent premaxilla management on bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2019;6:124-8

How to cite this URL:
Torres TI, Pedrero ML, Dodd JA, Robledo CA, Martìnez MD. Prominent premaxilla management on bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2019 [cited 2019 Aug 21];6:124-8. Available from: http://www.jclpca.org/text.asp?2019/6/2/124/264092


  Introduction Top


The cleft lip and palate (CLP) is the most frequent congenital craniofacial malformation.[1],[2],[3] The anatomy of the bilateral cleft lip and palate (BCLP) presents a displacement, and protruded premaxilla, the nasal cartilage is displaced and the columella is diminished.[4] Ideally, the treatment should be performed at an early age to avoid complications that prevent the closure of the lip.[5],[6],[7]

The presurgical orthopedic has to objective relocation of the protruded premaxilla before the repair of the cleft lip.[8],[9] Surgical management is an alternative to relocate premaxilla; some options are amputation of the premaxilla and premaxilla surgical retroposition;[10] however, these procedures can alter maxillomandibular growth and the loss of dental organs.[11]

The objective of the case report is to present the late surgical-orthodontic approach of a patient with BCLP with prominent premaxilla.


  Case Report Top


Subjects and methods

A male patient of 3 years and 6 months of age, according to the classification of Kernahan and Stark, presented with bilateral CLP. The informed consent was signed by parents to take photographic records and beginning treatment. On the exploration can be observed protrusion of the premaxilla of 11 mm and an overbite of 8 mm [Figure 1]. According to the age and importance of the protrusion of the premaxilla, the treatment plan with the orthodontic surgical team to planning the surgical reposition of the premaxilla is decided to be performed.
Figure 1: (a) Frontal view, the protrusion of the premaxilla is observed. (b) Occlusal photo of dental casts. (c) Lateral view of articulated dental casts

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Orthodontic planning

Obtain dental casts to perform the simulation of the surgery, and it is determined to reposition the premaxilla 6 mm and lift the occlusal plane 4 mm. Once the simulation of the surgery in dental casts is performed, the surgical splint is elaborated with Polymethyl Methacrylate self-curing acrylic (PMMA) polished and checked in articulated dental casts that have no contact points that cause dental interference and can dislodge the surgical guide [Figure 2].
Figure 2: (a) Lateral view presurgical articulated dental casts. (b) Occlusal view dental cast simulation of the surgery. (c) Lateral view dental cast simulation of surgery

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Surgical management

General anesthesia and local anesthetic were applied to the mucous of the septum, and anteroposterior incision was made on the mucosa to expose and dissect the vomer bone. Once identified, a partial osteotomy of the vomer segment is performed in a triangular or wedge shape with anterior septal extension and excision of the wedge, with a measurement of ± 6 mm of base and ± 4 mm of height according to the surgical guide previously manufactured. Premaxilla preserves its irrigation through the contralateral vestibular-labial mucous and alveolus palatal mucous.

Once the osteotomy is finished, the surgical splint is placed to reposition and temporarily fix the premaxilla to the vomer by a Kirschner nail of 0.8–1.5 mm. It was decided to cement the surgical guide to the present dental organs in order to have a better consolidation [Figure 3].
Figure 3: (a) Occlusal view of cemented surgical splint after surgery. (b) Lateral view of the cemented surgical split

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Postoperative management

The observation was weekly appointments to assess the vascularity of the tissues, oral hygiene, and the stability of the premaxilla. During the follow-up, the patient was found to have an adequate evolution, and at 30 days postoperatively, the Kirschner nail and the surgical splint were removed to subsequently perform the bilateral lip closure using the modified Tennison-Randall technique.


  Results Top


After 6 months of the operative period, an improvement in the facial appearance was observed, the severe protrusion of the premaxilla was resolved with the surgical reposition, and this helped to close the primary lip. The premaxilla was reposed 6 mm, and the anterior occlusal plane was raised 4 mm, improving the overjet and overbite [Table 1]. Both the osteotomy and the lip closure were satisfactory procedures without observing vascular damage that compromised the vitality of the premaxilla, alterations in the consolidation in the zone of the osteotomy, or occlusal instability. The use of the surgical guide helped to predict and consolidate the premaxilla with the vomer.
Table 1: Measurements in millimeters (mm) that evaluate the changes before and after the surgical retroposition of the premaxilla

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The main objective of this procedure was to avoid the amputation of the premaxilla, using the osteotomy to decrease the distance between the premaxilla and palatal processes, this in order to be able to perform the labial closure in the future, the surgical reposition of the premaxilla was successfully achieved reestablishing nasolabial function, anatomy, and aesthetics [Figure 4].
Figure 4: (a) Frontal view before of the premaxilla reposition. (b) Subnasal view before the reposition of the premaxilla. (c) Lateral view before the reposition of the premaxilla. (d) Frontal view after the surgery reposition of the premaxilla. (e) Subnasal view after surgery the reposition of the premaxilla. (f) Lateral view after the surgery reposition of the premaxilla

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  Discussion Top


The main goals of the multidisciplinary team are to perform treatments at an early age, and the presurgical orthopedics has the purpose of restoring the anatomical structures as close to normal before the first lip surgery to reduce the postsurgical stress of the soft tissues. Presurgical orthopedics is based on the concept of Matsuo and Hirose, which mentions that the optimal time to take advantage of the amount of hyaluronic acid that allows to mold the palate, lip, and nose is before 6 months of age.[11],[12],[13] However, not always this goal is achieved, nowadays multiple patients attend for first time evaluation after the 1st year of birth. Treatment timing in clefts patient is an important factor, the alteration in the continuity of the alveolar process and orbicular muscle, as well as, the activity of the tongue against premaxilla are responsible for the growth of the nasal septum and the vomero-premaxillary suture, it, leads to an uncontrolled growth, malposition and protrusion premaxilla,[6],[14],[15],[16],[17] resulting in cases of bilateral CLP, lack of labial sealing and lack of anterior occlusal contact. Uncontrolled growth premaxilla threats the success of the primary closure of the lip, and one of the treatments to correct it is the surgical retroposition of the premaxilla.[6]

The anatomy of patients with bilateral CLP presents some alterations such as the delicate irrigation of premaxilla and prolabium;[18] for this reason, the surgical technique to perform the osteotomy must be careful.

In this clinical case, due anatomical characteristics described above and the risks in the vascularization, it avoided incision by vestibular and prolabium, in order to preserve and injure as little as possible the periosteum and the blood supply of the prolabium, and the mucous of the nasal septum, it was decided agree as reported by Sierra et al.[16] and Carlini et al.[19] Although Raposo-Amaral et al.[17] reported that there is no statistically significant difference in the appearance of the scar in patients with previous labial adhesion, in this case, once the premaxilla was consolidated, it was decided to close the primary lip, to reduce vascular deterioration and reduce the risk of necrosis in the prolabium and premaxilla.

The fixation of the osteotomy is an adjuvant that helps us to stabilize the segments to conserve the irrigation.[18] Although there are several resorbable and nonresorbable fixation materials, it was decided to temporarily fix the premaxilla with a Krisner nail and surgical guide due to the quality and quantity of premaxilla, as reported by Prada Madrid et al.[20] The surgical guide was fixed for 6 weeks with dental ionomer material, the guide was made based on the surgical planning of the osteotomy with rigid acrylic material, and this allows the surgeon to have a controlled guide and stable intraosseous fixation.

Miyasaka et al.[7] they proposed in a clinical case, a guide where a subsequent to the osteotomy was placing a tissue conditioner that is a soft acrylic, the main advantages reported of this surgical guide are; adjust to the palatine processes and premaxilla after the osteotomy, is removable and facilitates hygiene. In the clinical case presented, although the surgical guide was fixed, hygiene was resolved by manufacturing the surgical guide only covering the maxillary arch without extending to the palatal or vestibular mucosa.

The main indication to perform the surgical reposition of the premaxilla is to solve problems in the preschool stage that causes the inability to close the lip, dysarthria, problems in chewing, and esthetics.[7],[19] Surgical reposition of the premaxilla is a great challenge; however, this surgical procedure corrects alterations in horizontal and vertical dimensions, and the decrease in the distance of the fissure facilitates the placement of an alveolar bone graft that will provide continuity to the arch and allow the canine to erupt, according to Koh et al.[21] and Rahpeyma et al.[22] Not diminishing the amplitude of the fissure can provoke the appearance of anterior and nasoalveolar palatal fistulas and can compromise the lip closure, continuity of the arch, and predispose to fracture due to premaxilla trauma.

Some disadvantages of the surgical reposition of the premaxilla are low stability in the fixation of the premaxilla posterior to the osteotomy and the risk of the decrease of the growth of the middle third, causing maxillary retrusion.[7],[14],[15],[18] The risk of retrusion of the middle third decreases, if the osteotomy is performed after 8 years of age,[17],[19] however, for functional and esthetic purposes in our case had to be performed at 3 years with 6 months to perform the lip closure, although it is known that at this age the facial growth does not approach 80% proposed to perform the osteotomy, our clinical case agrees on characteristics such as age, and the severe protrusion of the premaxilla according to the Index of Orthodontic Treatment Need using by Koh et al.,[21] which reports in a series of cases of patients between 2 and 12 years of age submitted to the surgical reposition of the premaxilla and there was not observed statistically significant change on the maxillomandibular growth evaluating ANB angle, they propose that if the osteotomy not involve vomero-premaxillary suture, should not have impact on the growth.

Prominent premaxilla in the preschool stage not only causes functional and esthetic problems,[7],[19] but also it also involves the deterioration of quality of life, so planning to perform surgical-orthodontic procedures by surgical reposition premaxilla is necessary even if the maxillary-mandibular growth is compromised during the preschool and school stage. In this clinical case, planning surgical-orthodontic of the surgical retroposition of the premaxilla allowed that the lip closure, considering that this helps the patient to be included in the social environment, improving chewing, speaking and increasing safety and academic development.[7],[17],[22]

Although this is a technique that can compromise the growth and development of the middle third in children with CLP where growth has not been achieved at 80%, performing the osteotomy allows the reduction of the alveolar and labial fissures this, in addition to obtain psychosocial benefits that focus on the child's integration into society and the academic world; These are justifiable points to reposition the premaxilla and allow lip closure.

Limitations

Long-term evaluation is required to evaluate the growth of the middle third. The presentation of a clinical case prevents the evaluation of parameters and results in different patients.


  Conclusions Top


Lack of surgical and orthodontic treatment at an early age can lead to comorbidities that involve malocclusion, speech problems, and feeding.

The presence of labial cleft in preschool age can have repercussions on esthetic and social satisfaction, and these are aspects that should not be forgotten because it can affect their quality of life.

Surgical reposition of the premaxilla decreased the distance of the alveolar and labial fissures, and this allowed the closure of the primary lip to be achieved.

The planning of surgery with surgical guidance allowed the stability and precision of the osteotomy also that it was used as an appliance of fixing the premaxilla.

Long-term follow-up by the multidisciplinary team should be monitored to monitor craniofacial growth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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