A 34-year-old woman with CLP on the left side was referred to our department with a chief complaint of dissatisfaction with the appearance of her face and teeth (Figure 1). The patient had congenital UCLP and had previously undergone surgeries at other institutions, including cheiloplasty at 6 and 8 months of age and palatoplasty at 1.2 years of age. Bone grafting had not been performed.
Extraoral examination revealed a concave facial profile with maxillary retrusion and mandibular protrusion. There was evident facial asymmetry with mandibular deviation to the right.
Intraoral examination showed a Class III molar relationship on both sides (Figure 1). The maxillary arch was remarkably constricted, with severe crowding and anterior and posterior crossbites. There was mild crowding in the mandibular arch with an accentuated curve of Spee. Alveolar defects with oronasal fistulae were present on the left side.
Clinical and panoramic radiographs demonstrated congenital absence of the maxillary left lateral incisor, maxillary left second molar, and mandibular right and left second premolars (Figures 1 and 2A). In addition, the maxillary left central incisor, maxillary right lateral incisor, and maxillary left and right second premolars showed extensive crown structure loss due to severe caries, and only root stumps were remaining. The maxillary right central incisor, left canine, and both first premolars also showed caries. The majority of teeth showed significant gingival recession (Table 1).
Lateral cephalometric analysis revealed an A point-nasion-B point (ANB) angle of -4.1 , sella-nasion-A point (SNA) angle of 68.4 , and sella-nasion-B point (SNB) angle of 72.5 . The maxillary and mandibular central incisors were retroclined (Figure 2B; Table 2). Posteroanterior cephalometric analysis showed right-sided mandibular deviation by approximately 4.0 mm at the mental spine (Figure 2C). The maxillary occlusal plane inclination was not observed.
The patient's post-treatment records demonstrated a balanced facial profile and occlusion with improved facial symmetry (Figures 5, 6, 7). Her profile was dramatically improved, with reduced upper lip retrusion and lower lip protrusion as a result of the maxillary advancement and mandibular setback, respectively. Intraoral photographs showed satisfactory occlusion with adequate overjet and overbite and coincident midlines (Figure 5). The patient's speech function was re-evaluated by ENT specialists, who found no major changes. Gingival recession was slightly increased, but tooth mobility was within the normal physiological range (Table 1). No tooth hyperesthesia was observed after treatment. The patient was not willing to undergo any periodontal reconstructive surgery, so we referred her for follow-up to a periodontist. Post-treatment cephalometric analysis and computed tomography images showed an increased SNA angle (72.8 ), a decreased SNB angle (68.7 ), and an increased ANB angle (4.1 ; Figures 6, 7, 8; Table 2). The amount of advancement at the anterior nasal spine was 6.0 mm. With regard to the maxillary anterior tooth axis, the upper incisor to sella-nasion axis changed from 91.4  to 95.1 . Posteroanterior cephalometric analysis revealed a decrease in the amount of mandibular deviation at the mental spine from 4.0 mm to 2.0 mm. The post-treatment panoramic radiograph showed good root alignment. There was no discernible bone loss or root resorption, with no apparent post-treatment changes in either occlusion or the alveolar bone height in the grafted areas.
The occlusion remained stable, and good facial esthetics were maintained after 5 years of retention (Figures 9, 10, 11, Tables 1 and 2).