case_images: PMC10876923_01
case_images: Pre-treatment extraoral photographs: (a) frontal, (b) smiling, (c) profile.
case_images: cureus-0016-00000052643-i01.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i01.jpg
case_images: FIG1
case_images: No abnormality was detected on opening or closing of the mouth, and no abnormality was detected on palpating temporomandibular joint (TMJ) (Figure 1).
case_images: Pretreatment intraoral photographs: (a) left occlusion, (b) frontal view, (c) right occlusion, (d) maxillary arch, (e) mandibular arch.
case_images: cureus-0016-00000052643-i02.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i02.jpg
case_images: FIG2
case_images: Molar relation: Angle's Class I bilaterally (Figure 2). On further examination, it was seen that both the laterals of the maxillary arch were evaluated to be peg-shaped laterals (Figure 2d) and had Grade 2 mobility. Mild crowding was present in the maxillary arch (Figure 2d), and moderate crowding was present in the mandibular arch (Figure 2e). A cleft of the palate was seen extending from the alveolus to the third rugae, involving only the hard palate and shallow vestibule (Figure 2d, 2b).
case_images: Pretreatment radiographs: (a) orthopantomogram, (b) lateral cephalogram.
case_images: cureus-0016-00000052643-i03.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i03.jpg
case_images: FIG3
case_images: A pretreatment orthopantomogram (OPG) revealed an impacted permanent canine on the right quadrant, incomplete root formation of peg laterals, and erupting supernumerary teeth between the peg lateral and permanent canine on the left quadrant in the maxillary arch (Figure 3a). Radiolucency in the maxillary arch between the premaxilla and the palate is due to the oro-nasal fistula (Figure 3b). ABG within four months. ABG was planned early in the treatment as canine root formation was nearly complete, as seen on the OPG (Figure 3a).
case_images: L-loop appliance in the patient's mouth for alignment: (a) right occlusion, (b) frontal view, (c) left occlusion.
case_images: cureus-0016-00000052643-i04.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i04.jpg
case_images: FIG4
case_images: A 0.016 AJW arch wire was used to fabricate an L-loop that was placed bilaterally distal to the central incisor brackets; it was used to align the upper arch and procline the maxillary centrals (Figure 4).
case_images: Fistula closure and vestibuloplasty.
case_images: cureus-0016-00000052643-i05.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i05.jpg
case_images: FIG5
case_images: Initially, fistula closure and vestibuloplasty were conducted simultaneously, as seen in Figure 5.
case_images: Mid-treatment photographs with a cemented extended transpalatal arch (TPA): (a) left occlusion, (b) frontal view, (c) right occlusion, (d) maxillary arch with fixed extended TPA, (e) mandibular arch.. Pictures are taken by the author.
case_images: cureus-0016-00000052643-i06.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i06.jpg
case_images: FIG6
case_images: Once the patient was comfortable visiting the hospital again, it was observed that her canine was well erupted in the arch, indicating the success of the ABG in achieving the main objective of the start of treatment and also to close the oro-nasal fistula (Figure 6).
case_images: Alveolar bone grafting procedure: (a) donor site, (b) recipient site, (c) after closure.
case_images: cureus-0016-00000052643-i07.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i07.jpg
case_images: FIG7
case_images: Surgical repair of the naso-alveolar fistula was performed using a cortico-cancellous iliac bone graft from the left side under general anesthesia (Figure 7).
case_images: Prosthetic replacement of lateral incisors using the Marryland bridge: (a) right occlusion, (b) frontal view, (c) left occlusion, (d) maxillary arch, (e) mandibular arch.
case_images: cureus-0016-00000052643-i08.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i08.jpg
case_images: FIG8
case_images: Maryland Bridge. Metal-ceramic prosthetic lateral incisors were fabricated and cemented into the arch within a period of 15 days (Figure 8).
case_images: Post-treatment extraoral photographs: (a) smiling, (b) frontal, (c) profile.
case_images: cureus-0016-00000052643-i09.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i09.jpg
case_images: FIG9
case_images: Consequently, the patient's appliance was debonded (Figures 9, 10, 11).
case_images: Post-treatment intraoral photographs: (a) left occlusion, (b) frontal view, (c) right occlusion, (d) maxillary arch, (e) mandibular arch.
case_images: cureus-0016-00000052643-i10.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i10.jpg
case_images: FIG10
case_images: Consequently, the patient's appliance was debonded (Figures 9, 10, 11).
case_images: Post-treatment radiographs: (a) OPG, (b) lateral cephalogram.
case_images: cureus-0016-00000052643-i11.jpg
case_images: PMC10876923_01_cureus-0016-00000052643-i11.jpg
case_images: FIG11
case_images: Consequently, the patient's appliance was debonded (Figures 9, 10, 11).