Corresponding Author:


• Dr. Rohan Mascarenhas. Senior Professor, Department of Orthodontics and Dentofacial Orthopedics. Yenepoya dental college, Yenepoya University, Mangalore-575018. Karnataka. India
  Private Practice : Orthodontic and Dental Clinic , IInd Floor, B.A. Centre Point, Next to Taj Mahal, Signal Light Junction, Hampamkatta. Mangalore - 575001 -Karnataka , India.
  
  
• Dr. Tariq Ansari. Asst. Professor. Department of Orthodontics and Dentofacial Orthopedics. Yenepoya University, Mangalore-575018. Karnataka, India
  Private Practice : Orthodontic and Dental Clinic. IInd Floor, B.A. Centre Point, Next to Taj Mahal. Signal Light Junction, Hampamkatta. Mangalore - 575001

Introduction
Cleft Lip and Palate is one among the most common congenital abnormalities of the orofacial region. This condition develops in the 4th Stage of intrauterine development (1) . Many reasons have been cited for development of a cleft lip and palate such as a) Late pregnancy - Increases the risk of the first born to develop a cleft lip and palate (2 ) . b) Smoking - By the mother during pregnancy has been cited as a reason (3).c) Lack of the intrinsic shelf force- Prevents the palatal process from fusing with each other leading to the formation of a cleft palate (4) .d) failure of withdrawal of the face- from the chest during embryonic development causes failure of the tuberculum impar to assume an inferior position in the oral cavity . This leads to a physical interference by the between the two palatal processes resulting in the formation of a cleft (5).

Cleft lip is associated with a cleft palate in about 60% of the cases (6). The most mild form of a cleft is a bifid uvula. According to the extent of the cleft it has been classified by authors such as Veau and Kernhans. A cleft may involve the soft palate only or it may include the hard palate, alveolar process and the upper lip .

The cleft in the palate is observed to be in the median plane but as it runs interiorly it assumes a left or right direction in accordance to the line of fusion of the premaxilla with the maxillary process. This exhibits itself as an alveolar process defect between the Maxillary Lateral incisor and canine which may also lead to anomalies such as missing or impacted lateral incisors (7).

Effects of a cleft lip and palate range from aesthetics , severe psychological trauma to nutritional disturbances leading to malnutrition, oroantral infections, speech defects etc.

The primary objective of early Orthopaedic management of a cleft palate is to reduce the severity of the cleft and to closely adapt the premaxilla to the maxillary process which assists in the surgical management as the severity of the defect is reduced. There has been adequate debate on the early versus the late surgical management of a cleft case . In a majority of cases milliards rule of 10 is followed whereby the patient is to be at least 10 weeks of age with a 10 % Haemoglobin and at least ten pounds in weight (8). The early management is preferred as this reduces the severity of the defect as it is treated early; it assists in feeding and also prevents the child from having psychological problems in the formative years.

The late surgical management of a cleft patient is sometimes preferred by some surgeons as the argument lies in the fact that the patient has better developed bone mass for the surgery and also the increased immunity of the patient to post operative infections.

It is better to perform early orthopaedic treatment for a cleft patient with an anterior crossbite as this promotes the growth of the maxillary process and prevents the development of a prognathic mandible.

Cleft lip and palate patients are extremely conscious about their appearance and they generally tend to be shy, unmotivated and reserved. These patients require more motivation and encouragement during their treatment.

This case report exhibits the management of such a case with desired results.


Case Report
A 17 year old female patient presented with a history of cleft lip and palate on the left side , class I malocclusion with upper and lower anterior crowding , ectopically erupted maxillary right canine , a unilateral cross bite on the left side and a fractured and severely rotated left maxillary central incisor. The maxillary left lateral incisor was missing and there were over retained deciduous maxillary second molars. Radiographs confirmed the absence of the left maxillary lateral incisor and the presence of maxillary second premolars. There was also facial asymmetry on the affected side.

A pre-adjusted edgewise appliance was initially bonded to the maxillary arch and an 016" Niti round arch wire was placed in the maxillary arch for initial levelling and aligning .Space was created for the ectopically erupting maxillary canine with the help of an open coil NiTi spring which was placed along the arch wire between the right maxillary lateral incisor and the right maxillary first premolar.

Once sufficient space was created the maxillary canine was then bonded and ligated to the arch wire . The ligature was activated periodically till the canine was brought into the appropriate position in the maxillary arch.

The over retained deciduous maxillary second molars were extracted to allow eruption if the maxillary second molars

The lower arch was bonded with the straight wire appliance and an 016 " round Niti wire was placed in the mandibular arch one month after commencement of treatment .

After the canine was brought into place, the maxillary arch wire was engaged into the canine brackets. The posterior segment (from the molar to the first maxillary canine) was consolidated with a 009"stainless steel ligature wire. The 016" round Niti wire was then followed by the 019x025" rectangular Niti wire. Then the 019X025" rectangular stainless steel wires were placed in both the upper and the lower arch. An asymmetrical 019x025" stainless steel wire was placed in the upper arch to facilitate expansion on the left side to correct the unilateral cross bite ( fig 16) . This was continued till the completion of the expression of the right tip and torque of the bracket Cross bite elastics were placed between the upper and lower teeth on the left side to correct the crossbite

An open coiled NiTi spring was used to create space for the missing maxillary left lateral incisor.

After the above mentioned corrections and alignment of the arch a prosthetic ceramic bridge was placed between the left maxillary central lateral incisors and the left maxillary canine.


Results:
This case has been treated by non extraction . The molar and canine relationship were finished in a class I relationship .The ectopically erupted right maxillary canine was corrected, the unilateral crossbite was corrected and the crowding in the upper and lower arches were corrected .The maxillary left central incisor was derotated and space was created for the missing maxillary left lateral incisor . During treatment after the extraction of the maxillary over retained deciduous second molars the maxillary second premolars erupted and assumed their position in the maxillary arch . The profile changed from a concave to a straight profile.

The total treatment time was sixteen months with satisfactory results. A fixed retainer was bonded in the lower arch and a removable retainer with a bite plane was placed in the upper arch. The post treatment re evaluation was performed one year period after debonding and the results have been found to be stable.

A marked positive change was observed in the patients behaviour as the patient exhibited a very positive attitude at the completion of treatment.