International Journal of Dental and Health Sciences

Review Article Volume 05,Issue 04

ORTHODONTIC MANAGEMENT OF CLEFT LIP AND

PALATE: AN OVERVIEW
Abdul Baais Akhoon1, Mohammad Mushtaq2 and Syed Zameer3
1 Resident, Department of Orthodontics and Dentofacial Orthopaedics, Govt. Dental College and Hospital, Srinagar, J & K,
India.
2 Professor & Head of the Department, Department of Orthodontics, Govt. Dental College, Srinagar, J & K, India.
3 Associate Professor, Department of Orthodontics, Govt. Dental College, Srinagar, J & K, India.

ABSTRACT:
Cleft of the lip and/or the palate is a congenital birth defect which is characterized by complete or
partial clefting of the lip and/or the palate. The severity of clefting may vary from the trace of
notching of the upper lip to complete non-fusion of the lip, primary palate and secondary palate.
Facial clefts are seen due to non-fusion of the facial process. The cleft of the lip, palate and face may
be seen as an isolated birth defect, non-syndromic cleft or as a part of a syndrome with multiple
congenital anomalies called as ‘syndromic clefts’.
Patients with cleft lip and palate routinely require extensive and prolonged orthodontic treatment.
Orthodontic treatment may be required at any or all of four separate stages: 1) in infancy before the
initial surgical repair of the lip, 2) during the late primary and early mixed dentition, 3) during the
late mixed and early permanent dentition, and 4) in the late teens after the completion of facial
growth, in conjunction with orthognathic surgery.
This article discusses the various aspects of cleft lip and palate and its management from the
orthodontic perspective.
Key words : Cleft lip, Cleft palate, Orthodontics.

INTRODUCTION:

Historically, evaluations and Integration of services

hospitalizations of cleft patients were
done by independent caregivers. The The care of cleft lip and palate patients
American cleft palate-craniofacial require a number of specialists including
association was established in 1943. The psychologists and social workers to
association defined the role of provide a comprehensive treatment
orthodontist in a cleft palate team. from birth to adulthood. Treatment
course of a cleft patient and approach is
In 1972 craniofacial teams became based on the consultation among the
established as the extension of the cleft specialists involved with the cleft care.
palate team. The treatment protocols for However, during different stages of the
Cleft Lip and Palate management vary in physical and social development of the
cleft centres across the world with the cleft patient, role of one specialist may
underlying philosophy being the same. be more significant than the other.
Early rehabilitation of the child allowing
for normal development of
intermaxillary relationship.

*Corresponding Author Address: Dr. Abdul Baais Akhoon. E-mail: [email protected]

 Akhoon A. et al, Int J Dent Health Sci 2018; 5(4):552-576

Philosophy of Orthodontic Management Incidence of cleft lip/cleft palate : 1:800

– white Americans. 1:2000 – blacks.
•Overview of the problem Cleft lip/cleft palate account for 50% of
•Interaction with other team specialists reported cases. Cleft lip or cleft palate
•Evaluation of results alone account for 25% of reported cases.
•Acquisition of new knowledge
•Diagnosis In India :
•Management
•Overview of the problem - cleft lip + cleft palate : 1.25/1000
Knowledge of aspects like : incidence, - cleft palate : 0.46/1000
etiology, embryogenesis, neonatal Sex ratio :
anatomy and physiology enhances the
Cleft lip + cleft palate : males >
ability of the orthodontist to interact
females
with the team. Also necessary is the
Cleft palate alone : females >
discussions with plastic surgeons, normal
males
and cleft speech mechanisms,
Laterality of lesions :
maxillofacial prosthetic/Prosthodontic
techniques, social service problems and In case of unilateral clefts, left side
anatomical deviations and the is more frequently involved than the
techniques of lip palate closure. right side.

Incidence/Epidemology Increase in frequency :

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- with increase in parents age, There are several potential advantages
especially father. for informing parents of a prenatal
- consanguineous marriages. diagnosis of facial clefting:
Interaction with other team specialists
1.Psychological preparation of parents
Prospective / Retrospective and caregivers to allow for realistic
expectations at the time of delivery.
Prospective : 2.Education of parents on the
management of the cleft: presurgical
- proper diagnosis
neonatal orthopedics, plastic surgery for
- treatment planning
lip and palate closure, and alveolar
- prognosis
bone grafting.
Retrospective :
3. Preparation for neonatal care and
- leads to improvement in feeding.
rehabilitary techniques. 4. Opportunity to investigate for other
•Acquisition of new knowledge structural or chromosomal
•To alter one’s approach abnormalities.
•Determination of cost/benefit analysis 5. Possibility for fetal surgery.
•Recognition of variability in cleft An additional advantage of prenatal
population diagnosis of cleft lip and palate is the
•Impractical to attempt to treat all cases ability of the plastic surgeon to prepare a
alike customized plan of management for
•Maintenance of good longitudinal surgical repair of the cleft once the
records. sonologist characterizes the specific type
DIAGNOSIS: of cleft and describes the extent of the
anomaly.
Prenatal Diagnosis of Cleft Lip/Palate
With this information, the plastic
Ultrasonography is a noninvasive surgeon may wish to educate the
diagnostic tool now widely used as a parents about the severity of the
routine component of prenatal care. deformity, the need for any adjunctive
Ultrasonography serves to confirm fetal intervention before surgery, and the
viability, determine gestational age, predicted outcome of repair.
establish the number of fetuses and their
growth, check placental location, and Disadvantages of Prenatal Cleft
examine fetal anatomy to detect any Diagnosis
malformations.
Parents and professionals report an
Advantages of Prenatal Cleft Diagnosis emotional disturbance and high
maternal anxiety after prenatal diagnosis
of cleft lip/palate is disclosed. However,
parents of affected children strongly
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favor being informed and involved in Record of the timing and type of surgery
prenatal testing and counseling decisions performed to correct the defect.
and view this preparation as valuable
despite acknowledging the increased Well established differences in growth
anxiety and dysfunction during patterns and dimensions among various
pregnancy. As the sensitivity of types of clefts.
ultrasound screening in the detection of
Variations in frequency of dental
facial clefts increases, the potential exists
anomalies depending on cleft type ( 10-
for an increased number of families
25%).
choosing to terminate the pregnancy
even in the absence of other Potential complicating factors
malformations. Factors such as
perceived burden, expectation of - Mental retardation.
recurrence, religious and cultural beliefs, - Neuromuscular anomalies.
professional advice, and gestational age - Skeletal tissue anomalies.
at diagnosis are considered influential in -Frequent upper respiratory
the family’s decision to terminate infections
pregnancy. - Enlarged tonsils or adenoids
- Other forms of nasal obstruction.
A complex undertaking because of the 2. Social / Behavioral :
various complicating factors.
Behavioral characteristics lead to
Collection of records should begin at extremely poor oral hygiene.
birth
Poor prognosis for co-operation.
- every six months till the age of 2 yrs.
- every year after that. Patient “burn-out”.
Data base
Orthodontist should be willing to adjust.
- patient history
3. Somatic growth, development and
- clinical / radiographic examination
maturation
-systemic description of the occlusion
and analysis of the orthodontic records. Includes : - Clinical evaluation
A. Patient history - Serial ht/wt data
- Dental age
1. Medical / Dental history :
- Skeletal age
Primary importance to the accurate Infancy / “catch-up” growth
description of the type and extent of
Exhibit lower skeletal ages than normals,
cleft present at birth.
indicating delayed maturation. Aspects
like delayed dental development and

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retarded eruption to be considered in
terms of possible :

- Serial extractions
- Initiation of active treatment
4. Genetic / Family history :

Family history is significant as cleft

superimposed upon an underlying
skeletal growth pattern may vary from Clinical findings:
Class I, Class II, Class III.
- Forward rotation/position of pre-
i.e. In class III cases : immediate maxillary segment
attention - Tethered nasal tip
- Thin upper lip, protrusive lower lip
In class II cases : favourable
- Retrusive soft tissue profile
5. Habits : - Tongue thrust - Increased lower face height
- Finger/Thumb sucking - Lowered positioning of the tongue due
- Prolonged use of pacifiers to a constricted, scarred, obliterated
B. Clinical and Radiographic palatal vault
examination -Mouth breathing
-Enlarged tonsils.
1. Facial esthetics : 2. Intra-oral soft tissue :

In defects of palate only- facial esthetics

are usually close to normal.

In case of an extensively scarred palate,

there is a slight maxillary
underdevelopment leading to a straight
or mildly concave mid-face profile.

Also continued growth of the mandible Estimate of the extent , location and
and nose may worsen the profile. severity of palatal and alveolar scarring
provides a clue to :

1. Response of a palate to expansion

2. Degree of retention required.
3. Impediments to tooth movement.
4. Possible cause of altered tongue
posture.
Soft tissues potentially leading to altered
mandibular posture or function.
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Abnormal, scarred frenal attachments •Congenitally missing teeth (most
may affect the configuration of any commonly the upper laterals)
appliance. Monitoring gingival signs of •Presence of natal or neonatal teeth
developing periodontal disease related •Presence of supernumerary teeth
to poor oral hygiene. •Ectopically erupting teeth
•Anomalies of tooth morphology
3. Muscle balance and function : •Enamel hypoplasia
•Microdontia
The diagnosis and interception of
•Fused teeth
developing functional problems, from
•Poor oral hygiene leading to caries + pdl
early childhood through stabilization of
disease
the adult dentition is the most important
•Mobile and early shedding of teeth due
aspect of clinical evaluation. Functional
to poor periodontal support
alterations due to frequent occurrence
•Posterior and anterior cross bite
of severely malposed teeth, dental
•Protruding premaxilla
anomalies and skeletal dysplasia’s.
•Deep bite / open bite
Functional alterations : •Spacing and crowding
•Careful monitoring required as
1. Mandibular closure premature loss may lead to decrease in
arch length.
2. Tongue function + posture
•Soft palate muscles insert on posterior
3. Respiratory patterns.

Effects :

1. Unilateral crossbite in centric

occlusion

2. Pseudoprognathism (mixed
dentition)
margin of remaining hard palate rather
3. Problems of lip tonus + function. than midline raphe.
•Associated Dental Abnormalities
4. Dental problems •Supernumery Teeth- 20%
•Dystrophic Teeth- 30%
The presence of the cleft is associated
•Missing Teeth- 50%
with division, displacement and
•Malocclusion- 100%
deficiency of oral tissue. Cleft lip and
palate patients can have one or more of
C. Description of the occlusion and
the following features:
analysis of the diagnostic records

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Need to understand the basic D-A and Full deciduous dentition :
craniofacial development potential in the (BCLP < UCLP < CP = NORMAL)
cleft population. Subsequent skeletal growth might lead
to more severe problems.
According to Graber (1949)
Clinical significance:
- All children with clefts, if left
untreated are capable of achieving Re-expansion will invariably be
reasonably normal skeletal/dental necessary because of an incompatibility
relationships. in growth direction.

- Many of the present day Antero-posterior sagittal problems :

orthodontic problems are the result
of the treatment rather than the Variability and uncertainty due to gross
defect itself. displacement and distortions of
landmarks (i.e. ANS, PNS). In primary
Various problems encountered : dentition class III molar relationship /
ant.crossbite are of great concern.
1. Intra arch alignment and symmetry. Retroposition of the maxillary buccal
segments as a result of scar-mediated
2. Profile / esthetics.
“maxillary ankylosis” as proposed by
3. Transverse problems. Ross..

4. Sagittal problems. Clinical significance :

5. Vertical problems. 1. A-P problems worsen with age.

Intra arch alignment and symmetry : 2. Problem compounded by the normal

anterior expression of mandibular
Process of lip repair results in a growth.
generalized reduction in cleft width and
max. arch width dimensions. Intra-arch 3. Consideration to be given to the rest
malalignments appear with the eruption position of the mandible at the time of
of the deciduous dentition. Severe record taking.
rotations/lingual inclination of
permanent incisors in clefts involving the
alveolar ridge.

Transverse problems :

Infants : excessive max. width

dimensions
(BCLP > UCLP > CP > NORMAL)

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Vertical problems : all tend to get worse with further growth
and development.
Vertical contributions to the orthodontic
problem arise during the development of Role Of the Orthodontist
the mixed dentition:
Timing and sequencing of orthodontic
1. Progressively decreasing rate of care may be divided into four distinct
max. vertical development by the developmental periods. These periods
time of early permanent dentition. are defined by age and dental
2. Increased severity due to downward development and should be considered
and backward rotation of as time frames in which to accomplish
premaxilla. specific objectives. Such sequencing
3. Cant in the palatal plane. avoids the common tendency to allow an
4. Altered mandibular posture and early phase of treatment intervention to
assosiated increase in gonial angle. extend through infancy, childhood,
5. Excessive freeway space. adolescence, and into adulthood. With
6. Impeded vertical eruption of the understanding that children born
maxilla. with cleft lip and/or palate should be
7. Local disturbances in the vertical treated by an interdisciplinary team
eruption of teeth adjacent to the approach, the following four time
cleft. periods in the child’s development
8. Overclosure of the mandible provide a framework for discussing and
aggravates Cl III condition. recommending defined objectives.
9. Elongation of the facial profile.
Net result of this complex interaction - Timing of orthodontic treatment
the vertical deficiency tends to
Fishman
accentuate the A-P discrepancy b/w
jaws, and then both problems serve to 1. Pre-dental : (1-18 months )
create a worsening transverse
imbalance. The primary dentition cannot - prior to the eruption of the primary
be used to evaluate the magnitude of molars.
future problems. a) Pre-surgical
b) Post-surgical
Aim of cleft palate diagnosis 2. Deciduous dentition : (3-6 yrs)

Cleft palate orthodontic diagnosis must - after full eruption of the primary
evaluate potential problems in all three dentition.
planes of space, with both skeletal and
dental components. It must take into 3. Early mixed dentition : (7-9 yrs)
account features both common to and
- during eruption of permanent maxillary
unique for the various types of clefts, as
dentition.

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4. Late mixed and early permanent 6. To restore the oro-facial “functional
dentition : (9 yrs onwards) matrix”.
7. To help decrease the number of ear
Profitt infections.
8. Expand or prevent collapsed
1. In infancy i.e. before the initial
segments.
surgical repair of the lip.

2. During late primary and early mixed

dentition.

3. Late mixed and early permanent

dentition. In the late teens, after
completion of the facial growth in
conjunction with orthognathic surgery.

Predental Rx / Infant orthopedics( Mcneil,

Burston – 1950’s )

To align the distorted maxillary arch

segments orthopaedically in early
neonates, prior to any surgical repair.
This is considered as topic of heated
debate.

Approaches varied among different

centers:

- Active orthopedic movement

- Simple passive holding appliances
- With or without primary bone
grafting.
- Extra-oral pinned appliances.
Rationale / Objectives :
9. To reduce the need for later
1. To facilitate feeding. orthodontic treatment.
2. To help establish normal tongue 10. To allow soft tissue growth.
posture. 11. To guide tooth eruption.
3. Provide a psychological boost to 12. Improve esthetics.
patients/parents. 13. To reestablish sutural growth
4. Assist the surgeon in his initial patterns.
repairs.
5. Stimulate palate bone growth.

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According to cooper :

- Emphasis on minimizing total active

orthodontic intervention, limiting it
to what is required to achieve the
optimum results.

- Against any orthodontic/orthopedic

therapy.
1. Provide an aesthetically acceptable
- Patient’s monitored continuously.
and healthy dentition for life and to
- Questioned the claimed advantages contribute positively to the general
of pre-surgical orthopedics. facial form and appearance.

Opponents of presurgical orthopedics 2. Using appliances as simple as

put forth the following claims: possible.

Cleft always reduces in size without Pre-surgical period

presurgical treatment. The cleft
When introduced in 1950’s not accepted
invariably reduces in size following
in Oslo. Pre-surgical orthodontics was
primary surgery. Good surgical technique
used in Europe/USA for over 30 years
makes presurgical treatment unneces-
but did not demonstrate any long term
sary. All cleft babies can be fed
benefits in relation to:
satisfactorily without obturation of the
palatal cleft. Growth of the maxilla can 1. Facial growth
be inhibited by the use of lip strapping
and there is a greater incidence of cross 2. Appearance
bite.
3. Speech
Oslo approach ( 1948 ….)
4. Occlusion
One of the first cleft treatment teams,
based at two places : Bergen / Oslo. Definitive lip repair usually is achieved
Based on the principles given by Egil by the time the infant is 3 to 6 months
Harvold and Arne Bohn. Wilhelm old, and repair of the palate typically is
Loennecken (plastic surgeon) became a delayed until 12 months to 2 years of
part of the oslo team (1948) and age. Palatal repair is another
introduced a standard surgical procedure controversial issue, and many methods
for all cleft treatment. are available for repairing just the soft
palate or the hard and soft palate
Objectives :(Bergland) simultaneously. The rationale for the
timing of the palatal repair is related to

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the developing speech and language abnormalities which become increasingly
skills of the child, which typically evolve manifested later.
around the first year of age. This
rationale is usually in conflict with the Patient Follow up
effect of early surgical repair and the
•Patients seen regularly at 6 monthly
constraints of scar tissue on the growth
intervals for review.
and development of the nasomaxillary
complex. Early repair of the palate and •Motivating the family.
the resulting scar tissue may have an
effect on the growth and development •Generate early rapport with the child.
of the maxilla, which is reflected in the
•Constant monitoring of caries & oral
occlusion as a crossbite of anterior and
hygiene status.
posterior teeth. The severity of the
malocclusion has been associated with •Diet counseling.
certain surgical methods of palate repair,
and evidence from unrepaired clefts in •In some cases equilibration of
children and adolescents indicates that deciduous canines done to prevent
crossbites in the dentition rarely develop lateral shift of mandible.
in the absence of surgical repair and
resulting scar tissue. These appointments are made to
coincide with speech therapy to
Deciduous dentition decrease frequency of visits. Towards
end of deciduous dentition, intervention
Usually no treatment provided at this by face mask therapy if indicated.
stage because :
Interceptive Orthopedic Intervention:
1. Dental irregularities are usually How Early?
minor
Tindlund, 1994: found significantly better
2. No long-term benefits skeletal response when maxillary
protraction was started at the mean age
3. Does not ensure normal eruption of
6.3 years than later. The goal is to allow
permanent teeth
the permanent maxillary incisors to
4. Certain need of future orthodontic erupt spontaneously into a normal
treatment overjet & overbite relationship.
Protraction during the late deciduous
5. Evaluation of super-numerary teeth. dentition period reduces the unwanted
dentoalveolar protrusive effect on
Treatment can produce only temporary
permanent incisors. Younger patients are
results which would be poor
more co-operative than 10 year old.
compensations for deeper skeletal

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The orthodontist should consider many •Transverse expansion of the upper jaw
factors in determining when to initiate
orthodontic treatment during the •Anterior protraction of the upper jaw.
primary dentition stage. These factors
•Fixed retention by a palatal arch wire.
include the ability of the child to
cooperate, the severity of the Mixed dentition ( preparation for bone
malocclusion, timing of secondary bone graft )
grafts, and the need for future
orthodontic treatment in the early mixed The first alveolar bone graft was placed
or permanent dentitions. Contemporary in 1977 in Oslo based on the results of
opinion recognizes a need for cancellous bone grafts by Boyne/Sands.
orthodontic treatment in the early mixed Height of the inter-dental septum
and permanent dentitions. However, no assessed on intraoral radiographs. Best
strong evidence supports a benefit from results achieved when grafting done
routinely treating dental malocclusions prior to the eruption of the permanent
in the primary dentition, suggesting that canine.
orthodontic treatment may be best
Primary Vs Secondary bone grafting
delayed until it can be combined with
other treatment goals and thus shorten Primary Alveolar Bone Grafting. Most
the overall duration of treatment. cleft palate teams in the United States
have discontinued primary alveolar bone
Interceptive Orthopedic Treatment in
grafting in the neonate following a 5-
the Late Primary /Early Mixed Dentition
year post-treatment outcome study in
The aims of interceptive orthopedic 1972 by Jolleys and Robertson. However,
treatment at this stage are to: the case for early bone grafting has been
defended and, although controversial,
•Correct midface skeletal deficiency. continues to be practiced by several
institutions and craniofacial teams.
•Eliminate anterior and/or posterior
crossbite. Secondary Alveolar Bone Grafting. By
definition secondary or delayed alveolar
•Provide optimal space for spontaneous
bone grafting is performed after primary
incisors eruption.
lip repair. The age at which the bone
•Improve the soft tissue profile. graft is placed defines whether it is early
secondary bone grafting (2 to 5 years),
The rationale for orthopedic correction intermediate or secondary bone grafting
has been predicated on early transverse, (6 to 15 years), or late secondary bone
sagittal and vertical modification and grafting (adolescence to adulthood).
redirection of circum-maxillary growth in
all three dimensions : Intermediate or Secondary Alveolar
Bone Grafting (6 to 15 years of age). The
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success of this intervention requires in preparation for implants to be placed
collaborative treatment planning among when teeth are missing.
the orthodontist, surgeon, and other
team members. 5. Achieve stabilization and some
repositioning of the premaxilla in those
Secondary alveolar bone grafting offers patients with a bilateral cleft.
five main benefits: Controversies concerning alveolar bone
grafting require a rational and evidence-
1. Provision of bone support for based approach for resolution. These
unerupted teeth and those teeth controversies relate to the timing of the
adjacent to the cleft. If a bone graft is alveolar bone graft, the sequencing of
placed before eruption of teeth adjacent orthodontic treatment to correct a
to the cleft, it will improve the transverse discrepancy with palatal
periodontal support of those teeth. If a expansion, and the sites and types of
bone graft is placed after eruption of the bone for the graft.
canine, the bone will not improve the
crestal height of support and will resorb Timing. The timing of surgery depends
quickly to its original level. more on dental development than on
chronologic age. Ideally, the permanent
2. Closure of oronasal fistulae. By using a canine root should be half to two thirds
three-layered closure technique, with formed at the time the graft is placed.
the graft sandwiched between the two Permanent canine root formation
soft tissue planes, an increased success generally occurs between the ages of 8
rate of fistula closure has been reported. and 11 years. Rarely is the graft placed
before this time, although occasionally
3. Support and elevation of the alar base
the graft may be placed at an earlier age
on the cleft side. This benefit helps to
to improve the prognosis of a lateral
achieve nasal and lip symmetry and
incisor. Once teeth have erupted into the
provides a stable platform on which the
cleft site, their periodontal support will
nasal structures are supported. If this
not improve with a bone graft. Instead,
procedure is performed alone or is
the height of the crest of alveolar bone
combined with alar cartilage revisions,
resorbs to its original level. For this
improved aesthetic changes occur.
reason, performing the graft before the
4. Construction of a continuous arch eruption of the permanent canine is
form and alveolar ridge. This benefits the recommended. If the lateral incisor is on
orthodontist for moving teeth bodily and the distal side of the cleft, the graft
for uprighting roots into the cleft site. A should be placed earlier.
continuous arch form also benefits the
Sequencing. Secondary bone grafting has
surgeon and prosthodontist by enabling
been divided into early (2 to 5 years of
a more aesthetic and hygienic prosthesis
age), intermediate (6 to 15 years of age),

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and late (16 years to adult). Since osseous margins of the cleft. Cancellous
Bergland et al published the results from bone taken from the ilium, cranium, or
the Oslo study in which 378 consecutive mandibular symphysis is then packed
patients had undergone alveolar bone into the cleft defect. Cancellous bone is
grafting, contemporary opinion supports preferred over cortical bone because it
the intermediate period as the most revascularizes more rapidly and is less
appropriate time for grafting. Bone likely to become infected. Once the cleft
grafting in the intermediate period has defect is packed with bone and the
the greatest benefits and least risk for margins are overpacked, soft tissue
interfering with midfacial and coverage of the graft is required. The
skeletodental growth and development. surgeon determines the choice of the
The sequencing of procedures donor site from which the bone is
surrounding alveolar bone grafting harvested. Traditionally, the iliac crest,
requires interdisciplinary communication ribs, and tibia have been used because of
and cooperation resulting in better and their abundant supply of cancellous
more predictable patient care. The bone. The morbidity of harvesting bone
general or pediatric dentist ensures that from these sites results in most patients
any decayed teeth, especially those being hospitalized postsurgically because
adjacent to the cleft, are restored before of complications associated with the
the grafting procedure. Patient and donor site more so than with the
parents are instructed on good oral oronasal recipient site. The cranium has
hygiene practices to maintain at home. become an alternative site from which to
In addition, orthodontic treatment may harvest cancellous bone because of the
be required presurgically to reposition lack of associated discomfort and the
maxillary teeth that are in traumatic amount of hospitalization, time involved.
occlusion or to expand a severely However, the operating risks are higher
constricted maxilla, thus providing the and the abundance of cancellous bone is
surgeon better accessibility to the cleft less than from the iliac crest. The
defect. Any erupted teeth adjacent to mandibular symphysis is another donor
the cleft that have poor periodontal or site but should be recommended only
endodontic prognosis should be when the permanent mandibular canines
extracted at least 2 months in advance to have been located so as to minimize the
allow healing of mucosal tissues before chances of injuring these developing
surgery. teeth.

Surgical Technique. The grafting Orthodontic Considerations Associated

procedure uses tissue lining the cleft with Secondary Bone Grafting.
defect to construct a nasal floor and Orthodontic concerns regarding
close the nasal side of the oral-nasal secondary bone grafting relate to the
fistula. The cleft lining is elevated in a transverse dimension, incisor alignment,
subperiosteal plane that leaves bare the and eruption of the maxillary canines.
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The Transverse Dimension. Orthodontic Eruption of the Maxillary Canine.
expansion of the posterior segments Following surgery, the maxillary canine
preoperatively may improve the erupts through the graft. With
occlusion but also widen an existing orthodontic movement of teeth,
fistula. The expansion provides better sufficient space is created in the arch to
access at surgery for incision and allow the canines to erupt successfully.
elevation of flaps with closure of the Removal of unerupted supernumerary
palatal and vestibular oronasal fistulae teeth usually is performed at the time
following the cancellous alveolar bone that the bone graft is placed to create an
graft. Expansion also improves the unobstructed path of eruption for the
buccolingual orientation of the collapsed canine. Often the canine will erupt
posterior segment with the anterior rapidly following the bone graft. If the
segment, restoring arch symmetry. lateral incisors are malformed or absent,
Retention of the corrected crossbite with especially in patients with bilateral clefts,
orthodontic appliances postsurgically the canine is encouraged to erupt
may be indicated because the bone graft adjacent to the central incisors. Closing
is unlikely to stabilize the expansion. the edentulous space is an advantage,
thus avoiding the need for a prosthetic
Incisor Alignment. Alignment of incisors replacement of the absent lateral
adjacent to the cleft, which typically are incisors. However, “canine substitution”
rotated, displaced, or tipped, is limited needs to be considered in the context of
by the available bone into which the the occlusion, crown morphology, and
roots of the teeth may be moved. If the need for orthognathic surgery. Many
appliances have been placed of the orthodontic problems
presurgically, individual orthodontic encountered at this stage are effects of
tooth movements should be delayed early surgical repair.
until 2 to 6 months following placement
of the bone graft. The early movement Problems frequently encountered :
of the roots into the grafted bone
appears clinically to consolidate the - Malposed permanent incisors
alveolar bone and improve the crestal
- Posterior crossbite
alveolar height. The orthodontist should
confirm with the surgeon on the timing - A-P molar discrepancies
of tooth movement into the grafted cleft
site. In bilateral cleft lip and palate cases, - Serial extraction
a vertically extruded premaxilla can be
- Detection of dental anamolies.
repositioned upward with the use of a
labial intrusion archwire, moving the - Lingual appliance kept for 3 months
incisors en masse with the bone in post-operatively i.e. to enable the
vertical alignment with the posterior bone graft to maintain the
segments prior to bone grafting.
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transverse dimension of the basal
bone.
Maxillary incisors :

- Often erupt rotated, retroclined and

possibly in anterior crossbite.

- Corrected for esthetic reasons and to

facilitate oral hygiene ( labial archwire –
3/4 months )

- Less severe cases can be treated with a

maxillary Hawley plate or a finger spring.

Buccal crossbite attributable to segmental

displacement corrected simultaneously
using a palatal arch auxillary spring / Quad
helix / Removable screws.

Segmental repositioning :

- Done just prior to the bone grafting

procedure

- Care to be taken in relation to

severe antero-posterior hypoplasia.
Lip closure creates some constriction
across anterior part of maxillary arch.
In pt’s with BCLP, the mobile premaxilla
Similarly, cleft palate closure causes
is stabilized with a heavy rectangular
lateral constriction. Early orthodontic
archwire to ensure immobility.
interventions in anterior cross bite cases
A-P molar discrepancies : (cooper) to avoid permanent postural adaptation
of mandible. Retention of treated
- In Cl II cases : cervical pull headgear occlusion till completion of permanent
- In Cl III cases : reverse pull headgear dentition with a fixed or semi-fixed
(Delaire face mask) + chin cup lingual retainer.
therapy.

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Lateral crossbites corrected in a similar Quad helix : It provides controlled force
way. Correction of maxillary arch application to correct severe segmental
collapse prevents lateral shifts of distortion. Can be constructed chairside.
mandible, improves sagittal mandibular It has four sites of activation, exerting
position by circumventing adaptive three-dimensional control on molars;
mandibular prognathism. Provide area powerful anchorage mechanism.
for tongue, promote normal maxilla-
mandibular development & prepare arch NiTi expanders can also be used.
for secondary bone grafting. Semi-fixed
& fixed appliances are superior in
efficacy to removable appliances.

When maxillary expansion has been often useful during transitional phase of
significant & chiefly in canine-premolar dentition.
region - desirable to have open end of U-
shaped retainer facing posteriorly. Open end anteriorly allows intercanine
width maintenance when maxillary
Use of lingual sheaths & semifixed type premolars have replaced deciduous
designs serves four advantages: molars, which usually occurs before
permanent maxillary canines erupt.
1. Ease of making major adjustments. Severely rotated maxillary central
2. Replacements can be made at any incisors corrected for esthetic reasons,
time without increasing band inventory. facilitate oral hygiene, allow secondary
3. Time requirements are minimized. lip surgeries & avoid deleterious
4. Transition from expansion to retention sequelae on lower dentition & jaw
phase is immediate. relation. Semifixed appliances such as 0
To avoid wire crossing cleft site from by 2 ASTBA (anterior sectional twin
interfering with surgical bone grafting bracket appliance), employing reciprocal
procedures, retainer can be removed anchorage.
prior to intubation & secured back
immediately after extubation, allowing Erupting occlusion kept under
no time for relapse. Allows for rapid surveillance with help of OPGs as well as
replacement with second design, with guided with space management
open end facing anteriorly, which is procedures. 2 to 3 years after bone
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grafting usually when the cleft side Methods of correcting Maxillary
canine has erupted spontaneously hypoplasia
through the graft or has been surgically
exposed. •Reverse pull headgear

Orthodontic Vs Prosthodontic space •Distraction osteogenesis

closure.
•Orhthognathic surgery
Every effort is made to mesialize the
Before 1970, the chin cup provided
posterior teeth and to correct maxillary
mainly dentoalveolar retroclination of
hypoplasia. Maxillary hypoplasia is a
the mandibular incisors to correct the
common problem encountered in almost
class III incisal relationship with limited
25% of the cleft population – Ross (87).
effect. The introduction of the facial
mask for early protraction by heavy
forces to the maxillary complex in CLP
patients was reported by Delaire and
colleagues 1972.

Biomechanics of Conventional Reverse

Pull Headgear

maxillary sutures.

Design : Consists of Wire & acrylic

maxillary splint with occlusal coverage. It
is cemented with GIC. Provides
attachment sites for heavy elastics which
are engaged on to a splint anchorage
type reverse headgear (facemask).

Center of Resistance of Maxilla (Cres) – 1. Age and compliance of the patient

Postero-superior border of the 2. Amount of correction
Pterygomaxillary fissure. (Tanne) 3. Biomechanics ( Force Vector ).
Maxillary protraction (facemask)
Center of Resistance for maxillary
Indications
dentition – Between root apices of
deciduous molars / premolars.

Reverse pull headgear v/s Distraction

Factors to be considered:

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Sagittal deficiency of maxilla, anterior
crossbite, downward rotation of
maxillary plane, and low angle cases.

Age : Ideal age for Protraction headgear

is between 5-8 yrs. Early intervention
eliminates need for RME to free circum-

Angle of about 10 degrees to occlusal plane improve overall occlusal, esthetic &
& delivering 500 gm force on each side for functional prognosis.
14-16 hrs a day for 6-12 months. Rapid
correction of sagittal relation. Maxillary Main features include:
base protraction, canting of maxillary plane
• management of arches
upward, remodeling changes in anterior
maxilla & a backward rotation of mandible. •Tooth movements to finalize the
Avoided in patients with true mandibular occlusion
prognathism, very large sagittal discrepancy
in early childhood & in high angle cases. •Closure of spaces when possible or
planned space management in areas of
Permanent dentition – phase of missing teeth for prosthetic
comprehensive orthodontic care rehabilitation

Recognition of orthodontic limitations in • Pre- & post-surgical orthodontics

correction of malocclusion- “Therapeutic
diagnosis”. Comprehensive orthodontic Achieved by controlled force application,
mechanotherapy with fixed appliances to gently paced mechanics.

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Extraction decisions Removable quad helix design &
semifixed lingual retainer. Sectional
Fissural & supernumerary teeth near archwires for control of isolated
cleft mostly extracted for adequate bone segments. Utility arches are also
support to move or use them. Lower frequently applied (BCLP cases) to create
premolar extractions based on space desired moments for control of
needs in the arch & cephalometric goals premaxillary structures. Standard
set in accordance with maxillary arch. edgewise brackets allow good wire
bending capabilities for self-determined
Atypical extractions include a lower
control & freedom as per individual case
central incisor. Common in non-surgical
requirement. Built in three dimensional
compensation plans when space
control in straight wire appliance / pre-
requirements are minimal in lower arch.
adjusted edgewise appliance may cause
An edge-to-edge relation with the upper
restrictions by setting teeth to a mean
arch at the end of a non-extraction plan.
value of ‘normal’ non-cleft occlusion.
Bolton’s index reveals a larger
Riding pontics (Dr. Suri, Dr. Utreja, Dr.
mandibular tooth size ratio. Posterior
S.P. Singh 1999)
occlusion is favorable. Contracted or V-
shaped basilar arch is diagnosed Decision to close spaces vs planned
space management depends on amount
Advantages include :
of bone available to move teeth.
1. Rapid alignment of crowded lower Successful secondary bone grafts allow
anteriors. movement of teeth into graft site.
Missing upper anterior teeth affect facial
2. Accomodation of all remaining esthetics adversely. ‘Riding pontics’ are
incisors in the central trough of carefully selected acrylic teeth, which
bone which is often thin in cleft ride most efficiently on rectangular
patients. archwires. Enhance smile esthetics to
have a motivating influence during
3. Decreased need for overexpansion
comprehensive orthodontic therapy.
in upper arch.
Teeth selected chair-side with their
4. Maintenance of lower intercanine
shade, shape & size camouflaging well
width.
with adjacent teeth. Bracket bonded on
Midline centering not a goal, though to the pontic. Reversing preadjusted
always attempted. bracket to avoid lingual root torque
effect. Prevent gingival impingement by
Appliance designs & choice of appliance cervical end of pontic. Maintenance of
systems adequate hygiene. Support to depressed
upper lip.

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Figure 8 stainless steel ligature tie with Goslon Yardstick (Mars 1987) - useful
archwire ensures stabilization. Following indicator of severity of maxilla-
completion of orthodontic treatment, mandibular discrepancy, which can be
bracket debonded along with rest of the corrected by orthodontics or would
arch & acrylic tooth integrated into require maxillo-mandibular osteotomies.
retainer.
Severe skeletal discrepancy – surgical
Relapse & retention treatment plan. As patients grow, growth
deficiency becomes increasingly
Long-term retention is needed. It is apparent. Important to follow growth
provided by: pattern & not try to overcompensate
dentition to camouflage even when
-Soldered lingual retainers
unfavorable skeletal relationship
-Upper Hawley’s or circumferential develops. Surgery – usually maxillary
retainer with pontic to replace missing advancement. Bimaxillary surgery in
tooth. more severe cases, where otherwise
unreasonably large maxillary
Serves purpose of retainer, partial advancement required. Include severe
denture, obturator and helps in speech. malocclusions that result in
compromised mastication and speech
Precautions in treaing cleft patients
and nasal pharyngeal airway patency.
-Avoid overzealous tooth movement into
Current protocols include a LeFort I
cleft sites for want of adequate bone
maxillary advancement with
support.
concomitant fistula closure, and
-Mechanics should be gently paced. maxillary and alveolar bone grafting. Also
require mandibular setback surgery
-Abstain from proclining upper anteriors because of the severity of the maxillary
into tight-scarred upper lip. hypoplasia. Main disadvantage to this
two-jaw approach is that majority have a
-Longer treatment time. mandible that is normal in both size and
position or even small and retrognathic.
-Decision of orthodontics vs orthognathic
Setback of the mandible to reduce the
surgery to be judiciously made.
amount of maxillary advancement
-Expanded cleft arches maintained by compromises final lower facial form.
long-term retention.
Palatal fistulae & obturators
-Treated cleft cases followed up on a 6
Surgical repair of palate is aimed at
monthly basis till atleast 21 years of age.
restoring speech. Residual fistula at
Surgical vs nonsurgical treatment junction of anterior & middle third of
palate in some patients is difficult to
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close by surgical means & may require McCarthy in 1992 applied this concept to
palatal obturators. Occasional complaint the human facial skeleton and opened
of regurgitation is not an indication & the floodgates through which the next
patient/parents feel satisfied on being technical revolution in craniofacial
assured that there are no major surgery would pass. Clinically, distraction
consequences. Anteriorly located fistula osteogenesis consists of five sequential
contributes negligibly to speech stages (Mc Carthy, 1992) :
distortion. As fistula shifts more
posteriorly, more speech distortion & -Osteotomy
obturator becomes a compulsion.
-Latency
When an obturator has to be given,
-Distraction
patient instructed for proper oral
hygiene, palatal massage & routine -Consolidation
caries check-up. Acrylic teeth for
edentulous areas & palatal obturator for -Remodeling
improved speech may be motivating
When the maxilla is osteotomized as in a
factor for post-orthodontic retainer in
Le-Fort I osteotomy, the consideration of
maxillary arch – ‘three-in-one’ obturator-
vector will vary.
retainer-partial denture.
Center of mass for the maxilla – on the
Distraction osteogenesis
mesial aspect of the root of the upper
“ Biologic process of new bone permanent first molar.
formation between the surfaces of bone
segments that are gradually separated
by incremental traction”. Its origins can
be traced back to the work of Codivilla in
1905. Distraction osteogenesis was first
applied to the maxillofacial complex in
1972 by Snyder et al. to lengthen
mandible by an external fixation device.

Maxillary distraction is useful when

Surgical correction
maxilla needs to be moved forward a
considerable distance which by Popularized by Obwegeser. Most
orthognathic surgery may not be commonly used Le-Fort I osteotomy. Use
feasible. 25% to 60% patients require of secondry bone grafts.
maxillary advancement to correct the
maxillary hypoplasia & improve aesthetic Orthognathic Surgery
facial proportions. (Figueroa & Polley,
AJODO 1999)
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Treatment Planning. The timing and space for prosthetic replacement of the
sequencing of treatment require close teeth. The provision of space for surgical
collaboration of the team. The decision cuts between the crown and the roots of
to delay surgical orthodontic treatment adjacent teeth is also an important part of
until growth is stabilized may be sound the presurgical preparations. Ideally, the
but not always in the patient’s best patient is referred to the surgeon for a
interest, especially when psychosocial presurgical consultation, and the surgical
development is affected. In some movements are performed on mounted
instances, skeletal surgery may be dental casts. Close communication between
indicated before growth is completed, the surgeon and the orthodontist should
knowing that another procedure may be identify any occlusal discrepancies that may
necessary if the patient outgrows the prevent coordination of arches. The
correction. As a general rule, skeletal placement of full-size edgewise arch wires,
surgery, orthodontic intervention, and with lugs, provides a means of
final prosthetic rehabilitation should be intermaxillary fixation at the time rigid
completed before final soft tissue nose internal fixation is performed. After surgery
and lip revisions or rhinoplasty are is completed, the postsurgical phase of
instituted. The outcome of soft tissue orthodontics details the occlusion, which
surgical revisions, combined with should be completed within 4 to 6 months.
osteotomies for the mobilization of the
maxilla and mandible, is often CONCLUSION:
unpredictable until the skeletal
Facial clefting is the second most
discrepancy has been corrected.
common congenital deformity (after
clubfoot). Problems are cosmetic, dental,
speech, swallowing, hearing, facial
growth, emotional. The orthodontist is a
key member of the cleft palate team,
and is in a unique position to identify and
manage many of these problems.

The orthodontist’s role in the cleft palate

team requires close collaboration with
Role of the Orthodontist. A coordinated the other team members. The rationale
approach to the presurgical phase of of timing and sequencing of orthodontic
orthodontic treatment is indicated. Twelve treatment have been discussed in four
to 18 months of presurgical orthodontics periods of development:
are usually necessary to align the teeth,
(1) neonatal or infant maxillary
correct any compensations in axial
orthopedics,
inclination of teeth and any dental midline
discrepancy, coordinate arches, and localize

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(2) orthodontic considerations in the dental discrepancies. Provided that the
primary dentition, team members plan the timing and
sequencing of appropriate treatment
(3) mixed dentition to include
modalities in a closely coordinated,
presurgical considerations before an
problem-oriented approach, patients
alveolar bone graft is placed, and
with clefts should have optimal
(4) final treatment in the permanent functional and aesthetic results.
dentition with orthodontics only or Outcome measures for reporting the
combined with orthognathic surgery. The results of surgical interventions require
latter period combines orthodontic and the choice of valid and reliable measures
surgical approach to the correction of to be identified and implemented.
dental and skeletal components of
The ultimate outcome for team-based
malocclusion and facilitation of any
care is to have a fully rehabilitated
necessary prosthodontic treatment.
patient who is satisfied with the
Speech considerations and the treatment outcomes in terms of speech,
communicative skills of the patient with occlusion, facial and dental aesthetics,
a cleft are important aspects in planning and function. The patient should
orthognathic surgery for these patients. continue to receive conventional dental
Subsequent nose and lip revisions for and medical routine evaluations similar
cosmetic improvement must not be to any adult to maintain optimal oral
underestimated in the enhancement of health.
the final soft tissue facial aesthetic result
following correction of the skeletal and

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1. Om Prakash Kharbanda. cleft. Cleft Palate J 1986;

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988. 5. Markus AF, Precious DS.
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of the nasal septum on and palate. In: Booth PW,
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with congenital labiomaxillary Maxillofacial surgery. Ch. 29.
Churchill & Livingstone; 1999.

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