Correction of a prominent premaxilla in a juvenile with a bilateral cleft lip and palate using a novel, hybrid function regulator, the FR-BCPPm, followed by preadjusted fixed appliances: A 20-year follow-up

Abstract

A seven-year-old boy with a repaired bilateral cleft lip and palate, presented with a severe skeletal II base and an extremely prominent premaxilla. He had grossly incompetent lips with lower lip trapping, an 18.5-mm overjet, a deep overbite, markedly retroclined lower incisors, bilateral crossbites and 12-mm-wide alveolar gaps together with 6-mm vertical steps between the extruded premaxillary incisors and the posterior teeth. Before the eruption of the permanent canines, there was an urgency to approximate the opposing cleft alveolar margins and to level the split maxillary occlusal plane, in order to facilitate the successful insertion and subsequent consolidation of secondary alveolar bone grafts. A new functional appliance was therefore designed to achieve this objective, which drew components from Fränkel’s FR I and FR III function regulators. Together with a couple of novel components, it created a hybrid appliance, namely the function regulator for juveniles with a bilateral cleft and a prominent premaxilla: the FR-BCPPm. The patient was treated with this appliance and a nocturnal headgear at 7–13 years, together with a concomitant quad helix appliance followed by a transpalatal arch and bilateral bone grafts. He was then treated non-extraction up to the age of 17 years with preadjusted fixed appliances to correct his residual, crowded Class II malocclusion. The marked improvement in his occlusion, dentofacial appearance and his perioral function after a decade of treatment was then followed up over 20 years, during which time mild relapse of the incisor overjet and moderate recurrence of the lower anterior misalignment was noted two years after treatment. While no further relapse was observed at the four-year post-treatment review, by 20 years after treatment, a little further misalignment of the lower anterior teeth was noted, half of which was deemed to be attributable to age-related maturation.