279 Oral Rehabilitation of an Orthodontic Patient With Cleft Lip and Palate and Hypodontia Using Secondary Bone Grafting, Osseo-Integrated Implants, and Prosthetic Treatment SHINGO KAWAKAMI, D.D.S. MASAHIKO YOKOZEKI , D.D.S., PH.D. SHINYA HORIUCHI , D.D.S. KEIJI MORIYAMA, D.D.S., PH.D. Objective: Complete skeletal and dental reconstruction of the anterior max- illa is of great importance to patients with cleft lip and palate. Accordingly, osseo -integ rated implants have been utilize d for denta l recon struc tion after secondary bone grafting. In this report, the orthodontic management of a pa- tient with unilateral cleft lip and plate with associated hypodontia is described. The patient was treated with comprehensive orthodontic treatment in addition to secon dary bone graft ing, and denta l recon struc tion was achiev ed with a combination of osseo-integrated implants and fixed prosthodontic treatment. KEY WORDS: congenital missing, orthodontic management, oss eo-integrated implant, SBG Secondary bone grafting (SBG) of alveolar clefts in patients with cleft lip and palate is thought to be a reliable and highly predictable method of restoring the integrity of the alveolar ridge. SBG may aid the spontaneous eruption of the teeth ad- jacent to the cleft (Bergland et al., 1986; Paulin et al., 1988). It also allows for the orthodontic movement of these teeth into the correct position within the dental arch (Boyne and Sands, 1976; Enemark et al., 1985; Turvey et al., 1984). On the other hand, when hypodontia occurs in patients with cleft lip and palate, orthodontic treatment and dental reconstruction become extremely difficult because of the limited number of teeth pre- sent. On such occasions, a conventional fixed prosthesis or a removable partial denture has often been used for the oral re- habilitation of these patients. In recent years, osseo-integrated implants after SBG have provided a new alternative for the reconstruction of patients with cleft lip and palate. Previous studies have shown that bone graft stability is an important factor when performing restora tive interventions into the graft- ed bone (Kawakami et al., 2002; Rosenstein et al., 1997). Sat- isfactory SBG results would pave the way for implant insertion into the grafted bone (Ronchi et al., 1995; Takahashi et al., 1997; Triplett and Schow, 1996). This report describes the or- thodontic management of a patient with unilateral cleft lip and Submitted January 2003; Accepted May 2003. Address correspondence to: Keiji Moriyama, D.D.S., Ph.D., Department of Orthodontic s, School of Dentistry, University of T okushima, 3-18-15, Kura- moto-cho, Tokushima 770-8503, Japan. E-mail [email protected]. ac.jp. palate with hypodontia treated with an osseo-integra ted im- plant and followed by prosthetic treatment after SBG. CASE REPORT The patient, an 11-year-old boy with a repaired left complete unilateral cleft lip and palate (UCLP), was initially examined at the Tokushima University Dental Hospital. Clinical exami- nation revealed a Class III malocclusion with complete bilat- eral posterior crossbite caused by a narrow maxillary arch as well as an anterior crossbite. The right maxillary lateral incisor had erupted ectopically in a palatal position (Fig. 1). Evalua- tion of the panoramic radiograph showed that the maxillary left lateral incisor, the left and right second premolars and first molars, and the right third molar were congenitally missing (Fig. 2). The lower dental midline was deviated to the left, and the size of the alveolar cleft was quite large. Cephalometric analysis showed a skeletal Class III relationship with a retrud- ed maxilla point A-nasion-point B [ANB], 0.4 degrees; sella- nasion-point A [SNA], 75.3 degrees) as well as maxillary and mandibular incisors lingually tipped, as shown in Table 1. TREATMENT The trea tme nt plan con sist ed of imp rovi ng the comple te crossbite and correct the skeletal Class III relationship by an- terior and lateral expansion of the maxillary arch and anterior protraction of the maxilla. A quadhelix appliance for the max- illary expansion in addition to orthopedic protraction of the maxilla with a face mask were initially used. Standard edge- wise appliances (0.018 0.025) were bonded to the maxillary teeth for space maintenance and correction of crowding at the age of 12 years 10 months. The anterior and posterior cross-