Building a Smile, and So Much More

***This story appears in the UCLA School of Dentistry's Spring 2024 Magazine***

By Nancy Sokoler Steiner

Having worn braces for nearly six years, Heavenli Mayfield still doesn’t enjoy smiling. However, issues with her mouth – and nose – preceded the orthodontic alignment and went far deeper. Mayfield, now 19, was born with a cleft lip and palate. The condition not only affected her appearance but had physical impacts as well.

Her treatment began in infancy. It’s involved five surgeries, more visits to the UCLA School of Dentistry Westwood clinics than she can count, and support from the UCLA Health System to rectify her condition and bring about a cleft-free appearance she’s becoming more and more confident about

Chair of the School’s Section of Oral and Maxillofacial Surgery Wayne Ozaki, M.D., D.D.S., and Orthodontics Resident Tyler Brennan, D.D.S. ’22, Ortho/M.S. ’25, are the practitioners currently collaborating to bring Heavenli’s nearly two-decade case across the finish line.

Orofacial clefts, or cleft lips and palates, stem from a failure of the lip or mouth to form correctly. A cleft lip involves a separation of the skin and muscle between the baby’s nose and lips, while a gap in the tissue making up the roof of the mouth constitutes a cleft palate. Both can vary in size.

According to the Centers for Disease Control and Prevention, one in every 1,000 U.S. babies is born with a cleft lip and palate. A cleft lip can interfere with a baby’s ability to feed and, later, with a child’s ability to speak clearly. It can also cause problems with teeth and hearing, as well as frequent ear infections.

Mayfield’s case was more complex because her cleft was in the middle of the lip rather than appearing on one or both sides. Her condition involved deformities of the lip, palate, and nose.

“Having a cleft lip affected my social life,” she revealed. “When I was in second through sixth grades, I was bullied every now and then. It was mostly about my nose. When I was nine and in fourth grade, that’s when the bullying was the worst.”

Fortunately, she added, “I had a great group of friends who would remind me there’s nothing wrong with me and that kids can just be mean.”

“In general, when kids are young and have a significant deformity, they’re more introverted and shy,” said Dr. Ozaki, who has been following Mayfield’s case since 2009. “As we do more surgery, they grow more confident and outgoing and feel better about themselves.”

Mayfield was born at Harbor UCLA Medical Center in June 2004, so her condition was promptly recognized. At three months, she underwent surgery to close and repair her lips and nose, which improved her ability to feed. Another surgery to close the gap between her mouth and nasal cavity prevented further occurrence of fluid and food entering her nasal cavity. At the age of four, she had a bone graft to fill in the gaps caused by her cleft palate. Following that was a nose surgery at age nine to make breathing easier and improve the nose’s appearance. And in January 2024, Dr. Ozaki performed her final surgery, this time to the jaw. The orthognathic surgery involved a maxillary osteotomy to move her upper jaw forward and a sagittal split osteotomy to move her lower jaw back.

“The surgery to correct her protruding jaw was both functional and aesthetic,” said Dr. Ozaki, who holds a dual appointment as a clinical professor of plastic surgery at UCLA’s David Geffen School of Medicine. “She can chew better because her teeth are aligned, and her face is balanced.”

Before he could perform Mayfield’s jaw surgery, however, Dr. Ozaki engaged Dr. Brennan – now in his second year of residency – to optimize the placement of Mayfield’s teeth.

“Dr. Ozaki and I worked on the surgical planning for Heavenli’s case. That included determining how we wanted to move the jaw and how I needed to move the teeth to achieve the best result,” Dr. Brennan said. “Surgical planning is a very collaborative process, where we use physical models, digital models, CBCT scans, and virtual surgical planning software to determine exactly what movements we wanted to do during the surgery as well as what movements I needed to do prior to it.”

In addition, Mayfield was missing a front tooth, so Dr. Brennan worked on spacing her front teeth to prepare the area for restorations, which will be undertaken by colleagues in the School’s Section of Restorative Dentistry. “At the end of the day, what Heavenli is going to see when she smiles in the mirror is how her front teeth look, so we wanted to set things up for an ideal aesthetic result.”

Dr. Brennan notes that the orthodontic team becomes involved in cleft lip and palate cases when children reach seven to eight years old and their permanent teeth begin erupting. “We take steps to develop their dental arch, and then the surgeon does a bone graft. Early surgeries take care of soft tissue defects, but these patients typically lack bone, and a bone graft helps provide the periodontal support the teeth ultimately need. We try to time that just right so the permanent teeth erupt into that repaired area.”

Dr. Brennan emphasizes that many doctors, including orthodontics residents, worked on Mayfield’s case before he became involved as a first-year resident in 2023. “I’m just lucky to be here at the end and be able to finish it up,” he says. He anticipates that Mayfield will need only another six to 12 months of orthodontics to fine-tune her bite before she will complete her treatment.

Drs. Brennan and Ozaki both find working with patients like Mayfield professionally gratifying. “Some of the cases we do in ortho make a small difference for people: They have straighter teeth, which is great. But procedures like Heavenli’s are life-changing and make a huge difference,” Dr. Brennan said.

“Cleft lip and palate is my favorite surgery because it involves a lot of change,” Dr. Ozaki shared. “A lot of my surgeries involve solving a problem, so I only see the patient briefly. I like the continuity of meeting a child when they're a newborn, doing their surgery, and following their condition until early adulthood."

When considering where to complete his residency, Dr. Brennan chose to continue at UCLA due to his ability to work on craniofacial cases like Mayfield’s. In addition to hands-on training, he attended weekly craniofacial clinics where specialists including Dr. Ozaki, plus a pediatrician, a pediatric dentist, and an audiologist all see the patients together and discuss the cases afterward.

“Complicated cases are better treated in an academic environment, but I would love to treat simpler cleft lip and palate cases in private practice,” says Dr. Brennan.

As for Mayfield, she says: “I’ve been in treatment for a good while now. I’m truly excited to see the results. I feel like I’ll finally be comfortable and confident to smile showing all my teeth again.”

As she reflects on this experience, Mayfield – who is eyeing a future in veterinary medicine –appreciates the community UCLA Health helped cultivate for cleft lip and palate patients like her, both online and through in-person events. She also took time to acknowledge the veritable army of practitioners assigned to her case, including past orthodontic residents who have since entered private practice.

“It will be bittersweet once this chapter ends,” she said. “But I can’t wait to see what’s next for me and my new smile!”