CLEFT LIP &PALATE MANAGEMENT IN ORTHODONTICS /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
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Cleft lip and palate - Management
and role of orthodontist


Introduction
Epidemiology and etiology
Classification

Management
 Cleft lip and palate team
 Goals and objectives of treatment
 Various procedures undertaken from infancy
to adulthood
 Outline of various protocols used in different
centers across the world
 Conclusion

Introduction
Cleft lip and palate is the most common
developmental anomaly of the craniofacial
region, and they have been depicted
throughout in the past civilizations.
Records suggest that hare lip was
reported as far back as 1000 AD .


Management of these clefts patients have
been attempted with varying success.
Parea (1561), a French dentist was the
first to put an obturator to fill the cavity of
cleft in order to facilitate eating and
speech.


Le Monnier (1764), a French surgeon tried
to repair cleft palate surgically.
In following years, many attempts were
made to close cleft palate surgically but
failed due to tension developed at median
suture.
Fergusson (1844) and Van Langenback
(1862) greatly improved surgical
techniques for repairing clefts.

Keeping in mind that cleft patient need
services from specialist in different fields,
cleft palate centers were formed across
the world.
All these centers have cleft palate team
which work for common goal of “look
well, eat well and speak well”


At such a center, the cleft team may
appropriately evaluate the deformity,
coordinate a plan of care, and offer the
best attention to the patient.


The team is usually formed by a group of
professionals in the fields of plastic
surgery, pediatrics, speech therapy,
pediatric dentistry, orthodontics, oral and
maxillofacial surgery, and prosthodontics,
among others.


Over the years of treatment that cleft
patients require, the orthodontist is
involved in all stages of care to achieve
optimal dental and jaw relationships.


Epidemiology and etiology
The incidence varies widely and is the
least in the Negroid (Blacks).
The Mongoloids show the highest
incidence (Asian, mainly Japanese and
Chinese).
In India – 1 in every 750-800 live births

Gorlin and Cohen (2000) in their review
study of large series of patients with clefts
founded that approximately :
45% of cases have cleft lip and palate
25% have cleft lip only
30% have cleft palate only.


- Unilateral cleft lip tends to occur more
commonly on the left side (2 left:1 right).
- In general, more severe the defect, the
greater the proportion of males affected
cleft lip-palate, 2 males:1 female;
cleft lip only 1.5 males:1 female).

Etiology

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Genetics
Syndromes
Teratogens
Embryological basis


GENETICS
Much evidence supports the view that
genetic factors are associated with
orofacial clefting.
In twins with cleft lip-palate, concordance is
far greater for monozygotic twins (40%)
than for dizygotic twins (4.2%).
(Wyszynski and Beaty 1996)

various genes associated with orofacial clefting


SYNDROMES
Syndrome delineation involving orofacial
clefting has been discussed and reviewed
by Cohen and Bankier (1991).
By 1991, they have reported more than
340 syndromes. (Van der Woude
syndrome, Treacher Collins syndrome etc)

TERATOGENS
Teratogens responsible for birth defects
have been reviewed by Cohen (1997).
Cigarette smoking appears to be correlated
with clefting and may act alone or
synergistically with TGFa (Shaw et al
1996, Kallen 1997).

Tolarova and Harris (1995) reported that
dietary supplements of folic acid are known to
reduce the frequency of neural tube defects.
Mills et al (1999) studied the folate metabolism
in cleft palate and general population.
Their results strongly suggested that impairment
of folate metabolism may play role in the
etiology of orofacial clefting

EMBRYONIC BASIS OF ORO FACIAL
CLEFTING
Neural crest cells play an integral part in
facial morphogenesis.
Neuro-ectoderm form the skeletal and
connective tissue of the face: bone
cartilage, fibrous connective tissue (Sulik
1985, Cohen 1990)

Genetic and/ or environmental factors that
inhibit the flow of neural crest cells or
decrease their number may affect their
masses so that contact between the facial
prominences is inadequate or impossible,
leading to orofacial clefting, including
cleft lip and palate


Cleft palate may result from :
- Defective growth of palatine shelves
- Micrognathia may lead to wedging of
tongue between shelves hence causing
mechanical obstruction (Robin syndrome)
- Failure of fusion of palatine shelves
- Post-fusion rupture of shelves

Classification
- Facilitates communication among team
members
- Concise & clear description
- Comparison of progress among different
groups of patients


Davis & Ritchie(1922)
Group I - PRE ALVEOLAR CLEFTS
- clefts of lip (unilateral / median / bilateral)
Group II- POST ALVEOLAR CLEFTS
-clefts of soft palate
-clefts of soft & hard palate up to the alveolar ridge
-submucous clefts
GROUP III- ALVEOLAR CLEFTS
involving palate ,alveolar ridge & lip
(unilateral / median / bilateral)

Veau (1931)
Group 1- cleft of the soft palate only
Group2- cleft of the soft & hard
palate extending no further than
the incisive foramen ,thus
involving the secondary palate
alone
Group3-complete unilateral cleft of
the soft hard palate ,alveolar
ridge& lip
Group4-complete bilateral cleft of
the soft hard palate ,alveolar
ridge& lip

FOGH ANDERSON (1942)
Group 1 cleft lip only
Single- Unilateral or median clefts .
Double-Bilateral clefts
Group2 Cleft lip and palate.
Single-Unilateral clefts
Double-Bilateral clefts.
Group3 clefts palate only
extend up to the incisive foramen.

SCHUCHARDT AND PFEIFER'S
SYMBOLIC CLASSIFICATION (1963)


KERNAHAN'S STRIPPED ‘Y'
CLASSIFICATION
(1971)

Block I and 4 - Lip
Block 2 and 5 - Alveolus
Block 3 and 6 -Hard
palate anterior to the
incisive foramen
Block 7 and 8 - Hard
palate posterior to
incisive foramen
Block 9 - Soft palate


MILLARD'S MODIFICATION OF THE
KERNAHAN'S STRIPPED "Y" CLASSIFICATION
Millard added two triangles over the tip
of the "Y“ to denote the nasal floor.
This increased the number of boxes
to 11.
Block I and 5 - Nasal floor
Block 2 and 6 - Lip
Block 3 and 7 - Alveolus
Block 4 and 8-Hard palate anterior to
the incisive foramen
Block 9 and IO-Hard palate posterior to
the incisive foramen
Block 11- Soft palate.

ELSAHY'S MODIFICATION OF THE
KERNAHAN'S STRIPPED "Y"
CLASSIFICATION
Elsahy modified the Stripped "Y" further by
double lining the blocks 9 and 10 in the hard
palate area and used arrows to indicate the
direction of deflection in complete clefts.


He also placed a circle 12 under the stem
of the "Y" to represent the pharynx and a
dotted line from the Y to circle 12
reflecting the velopharyngeal competence.
Another circle 13 was also added to
represent the premaxilla, and the amount
of its protrusion was indicated by the
dotted line with an arrow.

ELSAHY'S
MODIFICATION


LAHSHAL CLASSIFICATION
(1987)
This is one of the simplest classifications
and was formulated by kriens o.
LAHSHAL is a paraphrase of the anatomic
areas affected by the cleft.


Management and role of
orthodontist


The functional and aesthetic problems
associated with cleft lip and palate depend
on the size of the cleft and whether it is
unilateral or bilateral.


All complaints are dealt by cleft palate team to
restore aesthetic and functional harmony.
Goals and objectives of treatment are to :
1. Close vestibular and palatal oronasal fistula
2. Restore physiologic continuity of the dental arch
to enable oral and dental health to be
maintained


3. Provide bone for stability and continuity of
the dental arch (bone grafting)
4. Allow eruption of the permanent teeth or
placement of dental implants through
bone graft.
5. Provide support for the lateral ala of the
nose


6. Orthodontic alignment of teeth
7. Facilitate nasolabial muscle and soft
tissue reconstruction
8. Establish functional nasal airway
9. Provide support for the lip
10. Prevent tooth loss caused by lack of
periodontal bone support

Role of the Cleft Palate Team Members
Plastic and Oral and Maxillofacial Surgeon
All surgical management of the cleft patient is
performed by these surgeons.
They evaluate the effects of lip and palate
surgery and do extensive planning in surgical
procedures, including secondary corrections of
the lip-nose and palate deformities, bone
grafting, and surgical-orthodontic treatment.

Pediatrician
The pediatricians advise on nutrition and
physical condition. Also, they make
recommendations for the appropriate
timing for surgery.
Speech Therapist
The speech therapist evaluates speech
and language development.

Pedodontist
The pedodontists are responsible for the
prevention of dental caries. When patients
are admitted for lip or palate surgery, the
pedodontist educate parents about oral
hygiene.


Prosthodontists
Prosthodontists are usually concerned with
the permanent replacement of missing
teeth or severe tissue defects following
surgical and orthodontic treatment.


Orthodontist
Role of orthodontist extends from infancy
to adulthood and during this long period of
service, he actively participate by :
 Facilitating surgical repair of cleft lip and
palate by aligning cleft segments
 Removing any interference to normal
growth
 Preparing cleft sites for grafting

 Analyzing maxillomandibular growth
harmony/disharmony
 Attempt to modulate growth
 Integrating surgical and orthodontic
treatment.
 Providing good occlusion


Various procedures undertaken from
infancy to adulthood (in sequence)



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

Presurgical orthopedics
Lip repair
Alveolar molding
Primary bone grafting
Palatoplasty
Expansion during primary dentition

 During mixed dentition
Alignment of arches
Expansion and protraction of maxilla
Secondary bone grafting
 During permanent dentition
Establishment of occlusion
Camouflage of skeletal discrepancy
Preparing patient for orthognathic surgery
 In adulthood stage
Orthognathic surgery
Esthetic surgeries

Presurgical orthopedic treatment
Presurgical orthopedic treatment is
undertaken to prepare an infant with a
cleft for surgical repair of the lip.
The technique is derived from the work
begun by Kerr McNeil, a prosthetist in
Glasgow, Scotland (1947).


Impression is taken as soon as possible
after birth and an appliance inserted within
the first 24 to 48 hours.
Appliance may be in form of passive
plates which merely obturate the cleft, or
active that attempt to move the segments
and reduce their displacement.

Passive
presurgical
appliance


Active presurgical appliance
McNeil's used active appliances which are
made by cutting the model along the line
of the cleft and repositioning the segments
The plate is then constructed on this
modified model, so that when worn, it
gradually corrected the position of the
segment.

Over the past 5 decades, there is strong
controversy regarding whether presurgical
orthopedics therapy should be an integral
part of treatment or it’s entirely trauma,
physical to infant and psychological to
parents.


Proponent strongly recommend
presurgical orthopedics based on their
following observation :
- Presurgical orthopedic treatment facilitates
feeding
- by narrowing the cleft, it reduces the
amount of muscle that must be freed to
produce a tension-free repair of lip.

- As far as skeletal growth concerned, Ross
(1987) came to conclusion. "Presurgical
orthopaedics in the neonatal period has
no apparent long-term effect on facial
growth."


On the other hand, various studies demonstrated
ill effect of presurgical orthopedics :
- Prozansky (CPJ 1964) - reported interference
with normal growth & development of maxilla.
- Friede & Pruzansky (CPJ 1985) evaluated the
long term effects of presurgical orthopedics and
observed sagital deficiency of the premaxillary
segment

- Shaw & Mars(1996) reported better
outcome in those centers that didn't
practice presurgical orthopedics
- Berkowitz(1996) concluded “the present
consensus is that these procedures offer
less long term benefit than expected”.


Jean Delaire (2000) admits the
supplemental role of infant orthopedics to
plastic surgical procedures during lip
closure without any long term effects on
growth.


Most obvious advantage of presurgical
orthopedics is seen in complete bilateral
cleft lip and palate where protruded
premaxilla prevent satisfactory lip closure
without previous alignment with the help of
orthopedics.


Role of
presurgical
orthopedics
in bilateral
cleft patients


The general opinion is that presurgical
orthopedics is an useful preliminary
measure that should be carried out
whenever possible provided that it does
not impose too much on the parents and
patient.


Lip repair
Once the segmented are aligned with
presurgical orthopedics if used, lip are
ready to be repaired surgically.
Timing of lip repair
Healthy infant can undergo surgery
anytime after birth.

It is preferable to wait at least until the end
of the third month when labial musculature
has developed significantly to adequately
support sutures
Moreover, immune system of child also
develops significantly


These are the reasons for the universal
acceptance of Millard's rule of 10.
According to Millard's rule of 10 –
infant should be at least 10 weeks old, 10
pounds weight with 10 % Hb


In bilateral complete clefts where
premaxilla is lengthened and often
considerably advanced, it is preferable to
close both sides of the cleft lip
simultaneously using two step protocol.


During the fourth month, primary lip
adhesion is undertaken (Johanson,1954)
This procedure starts aligning premaxillary
cleft segments under the influence of
physiologic lip force.


Three months later, during the seventh
month, the dentoalveolar elements of the
premaxilla are adequately aligned which
permit closure of remaining cleft of lip


Choice of Lip Repair
Tennison and Millard repairs are
preferred procedures and both are
modification of Z-plasties.
These techniques does not discard fullthickness vermilion, so natural lip contour
is restored.

Alveolar molding
A passive alveolar molding appliance is an
attempt to control the segmental
relationships of cleft segments by guiding
the forces produced by lip repair.
(Rosenstein 1969)
Lip forces can cause collapse of the
alveolar segments if left unsupported.

Typical arch alignment of
the maxilla of patient at
birth with a complete
unilateral cleft.
Maxillary arch alignment
which usually results after
lip closure without early
segment guidance.


In unilateral cleft lip and palate, the lesser
segment is held passively by the
appliance while the greater segment
rotates, ultimately abutting with the lesser
segment.


Molding passive
appliances which
maintains relation of
arch segments as
larger segment
responds to molding
pressure of surgically
closed lip.


In bilateral cleft lip and palate, both lateral
segments are held passively while the
forces of lip closure move the premaxillary
segment posteriorly to abut and align in a
relatively normal arch configuration.


The appliance is placed either before or at
the time of lip closure. It is not removed for
about a week after the surgical procedure,
in order to allow the lip to heal.
Thereafter it may be removed daily or as
desired for cleansing.


Rosenstein (1969) claimed that there Is
no growth attenuation, either antero
posteriorly or laterally due to the presence
of the appliance
Thus, the appliance, when passively
placed, has no untoward effect on growth.


Once the butting of the segments has
occurred, primary bone grafting if required,
is performed.
The appliance is kept in place to aid in
graft stabilization until the palate is closed,
at which time the appliance is discarded.


Primary bone grafting
Primary bone grafting is performed along
with the primary repair surgeries. (usually
before the age of 18 months)
(Dado, Cln.Plast.Surgery,Oct 1993)


Although the first reports of primary bone
grafting were published in the German
literature by Lexer (1908) and Drachter
(1914), the procedure was not popularized
until the l950s, when Eduard Schimd
extensively used this primary grafting
technique.


Goals of primary bone grafting
-

Preserve & improve the arch form
Stabilize a floating premaxilla in B/L CLP
Achieve tooth eruption in the area of cleft
Achieve functional & esthetic goals by
closing the defect

Protocol (Dado Cln. Plast. Surgery, 1993)
- Performed after lip repair but before palate
closure
- Done in conjunction with molding appliance
- Graft is placed only after the alveolar segments
are molded & grown into a butt joint
- Minimal soft tissue dissection of the alveolus &
maxilla

Ideal arch alignment prior to primary bone
grafting.


There is long lasting controversy regarding
cost/benefit ratio of primary bone grafting.
Although at one time this procedures was
done routinely, but over the years, use of
primary grafting is reduced significantly.


Proponents claim the following advantages
of primary bone :
- Prevention of maxillary collapse (Pickrell,
Quinn, and Massengill 1968)
- Improved bony support that enhances
soft-tissue repair (Freide, Johanson
1974)

- Improved ability to eat and enhanced potential to
develop normal dentition. (Nylen, Körlof,
Arnander, et al.1974)
- Support for the alar base (Abyholm, Bergland,
Semb 1980)
- Significantly fewer anterior and posterior
crossbites (Helms, Speidel,and Denis 1987)

- No facial growth attenuation -long term
longitudinal evaluation (Steinhauser1987)
- No inhibition of facial growth or maxillary
segment collapse (Rosenstein,1991;
Dado1993)

Opponents of primary bone grafting claim that :
- The graft does not keep pace with vertical
development of the alveolar process (Jolleys,
Robertson.1972)
- Inhibits lateral and anterior growth of the maxilla.
(Rehrmann, Koberg, Coch H. 1970)
- Restriction of maxillary growth in all three
palnes
(Hoberg, I970; Friede & Johnso, 1982)

- Controversial, counterproductive with growth
restriction in long term (Wits enberg, 1987)
- Poor outcomes are associated with primary
bone grafting (Shaw & Mars, 1992)
- Retrusion of maxilla due to growth inhibition
(Shafer, 1995)

Stal (1998) concluded that primary bone
grafting has fallen into disrepute because
of limited experience & variability of
protocol


Jean delaire (2002) recently reviewed
primary bone grafting procedures and
came to conclusion that the main factor
responsible for any ill effect produced by
primary bone grafting is surgical trauma
(scar) to palatal tissue which subsequently
interfere with normal growth.


Therefore, if performed carefully, there
may not be any growth interference but
the main factor which discourage primary
grafting procedure is insufficient amount of
bone during eruption of permanent
dentition which invariably need another
secondary bone graft.


Deficiency of
bone at age of 8
years in spite of
primary bone
grafting done at
age of I year.


Hence, if anyways we have to perform
secondary bone graft, then why to take
any possible risk of growth retardation with
primary bone graft. (Jean delaire, 2002)


Palatoplasty
Objectives of palatoplasty
The major objectives of a cleft palate
surgeries are :
1.To produce anatomic closure.
2 To produce normal speech.
3. To minimize maxillary growth inhibition
and dentoalveolar deformities.

Timing of palatoplasty
Veau (1952) suggested that the best time
to close the palate (hard and soft) is at the
age of 18 months.
Malek (1983) advises closure of the soft
palate before the lip to allow development
of normal speech pattern (integrity of soft
palate is must for normal articulation).

Jean delaire (2000) recommend
simultaneous closure of the soft palate
and the lip.
But closure of the hard palate at this time
leads to major problems with growth in this
area of great activity.


It is better to delay closure of the hard
palate until the age of 18 months, by
which time defect become sufficiently
narrow and can be closed with only
minimal displacement of the palatal
maxillary fibromucosa. (less scar tissue)


In the exceptional cases where cleft is too
wide, it is better to postpone closure to the
end of the third year, by which time all the
deciduous teeth have erupted.
(erupted deciduous molars acts as guide
and stabilizing factors by articulating with
mandibular teeth)


In more severe cases in which the maxilla
fails to respond to palatoplasty as
expected, it is better to postpone palate
closure till the age of 5 - 7 years.
(when it is possible to maintain the correct
dimensions of the palatal arch by a fixed
orthodontic appliance).


Treatment in deciduous dentition

Primary objective of orthodontic treatment in the
primary dentition is to correct crossbite which
may interfere with normal growth.
Almost in all cases, cross bite at this stage is
posterior cross bite.


Possible causes for this cross bite are :
- The most obvious cause is hypoplastic
maxillary segment on the cleft side
- Palatal scar tissue resulting from traumatic
surgery
- The canine adjoining the cleft will erupt
palatally because of the displacement of
its developing tooth bud.

Timing of treatment
Awaiting full eruption of the deciduous
dentition before initiating orthodontic
treatment can be important because the
mandibular arch affords an excellent basis
for determining where to position the
distorted maxillary parts and the dentition.

In most of the cases, occlusal interference
in canine region leads to mandibular shift
and gives impression of buccal cross bite.
Before attempting expansion, this possible
cause should always be eliminated.


Contact between the palatally
displaced primary canine
on the cleft side with the mandibular
canine causes a mandibular shift
and subsequent crossbite occlusion
(A-C).
Reduction of the cusps
corrected the occlusion.


If cross bite still persist, orthodontic
expansion can be undertaken.
Because there is no bony union at
midpalatal area, very light force by any
appliance (quad helix etc) can accomplish
the job.


Orthodontic forces move the unfused bony
maxillary segments containing the erupted
deciduous teeth as well as unerupted
permanent teeth.
This separation of unfused maxillary
segments is absolutely desirable in cleft
patients.
(Subtenly and Brodie 1954)

One of the reason not to perform primary
bone graft is avoidance of any bony union
between maxillary segments which will
prevent separation/expansion at this
stage.


Retention after expansion
Some form of prolonged, adequate
retention is imperative because it may not
be possible to stabilize the effects of the
adverse muscular forces and soft tissue
constrictive influences.


Because retention appliances may be lost
by young child, a fixed or cemented, welladapted, maxillary lingual arch appliance
is recommended.


In case where palatal closure is delayed till the
age of 6-7 years, It is recommended that
removable, palatal coverage retention be
constructed in addition to the fixed arch wire
retainer.
The coverage can serve the added function of
anterior obturator while the fixed retainer
maintains the stability of the repositioned bony
parts.

Treatment in mixed dentition
Primary goal of orthodontic treatment
during mixed dentition is to prepare cleft
area for secondary bone graft.
But all the alignment tasks and cross
bite corrections should be achieved
before graft placement.

Invariably, there are rotations and
displacements of teeth especially near the
cleft site.
Subtenly and Ogidan (1983) studied
patterns of eruption and malalignment of
the permanent incisors and cuspid teeth.


They found that :
- incisors bordering the cleft erupted downward
and backward into a position more retroclined
than normal and almost always with rotations
- Maxillary cuspids closely approximating the cleft
were found to be positioned more palatally with
crowns tipped toward the cleft and distally
inclined roots.

Controlled positioning of the permanent
anterior teeth can aid in more adequate
development of the alveolar bone
surrounding cleft.
Correction of malpositioned teeth is best
accomplished by using fixed appliance.


Cross bite correction
About 70% of cleft palate children
demonstrate severe malocclusion in form
of anterior and posterior cross bite during
early mixed dentition stages.
(Dahl , Hanusardottir 1979)

There should not be any posterior or
anterior cross bite by the time of graft
placement.
Orthodontic expansion of maxilla should
precede bone grafting because once a
bony bridge is established in this region,
cross bite correction becomes difficult.

Expansion can be achieved by :
Slow maxillary expansion
quad-helix
Nickel Titanium Expander
Rapid palatal expansion.
Advantage of RPE is that it can be used along
with maxillary protraction.

Nickel Titanium Expander
Unlike normal patients, one has to be very
careful regarding force level in cleft patients.
A tandem-loop, nickel titanium, temperatureactivated palatal expander with the ability to
produce light, continuous pressure is very useful
tool for arch expansion in cleft patients.


A Degree of
compression when
prototype appliance
was chilled to 20°
below transition
temperature.
B. Effect of shape
memory when
appliance was
warmed to body
temperature.

NiTi expander in cleft patient


Rapid Maxillary Expansion in Cleft Lip
and Palate Patients
Like normal individuals, the pattern of
expansion is triangular with a greater
opening in the anterior region.
But as there is no midpalatal suture,
expansion moves unfused segments
apart.

Rapid expansion opens circum-maxillary sutures
(e.g zygomatico-maxillary, fronto-maxillary etc )
which displaces the maxilla forward and
downward, opening the bite and moving Point A
anteriorly.
Also, loosening of these sutures help in
protraction of maxilla with reverse headgear/face
mask

Activation schedule in cleft patients
The appliance is first activated with four quarter-turns 24
hours after placement.
For the next four days, the screw is activated two quarterturns in the morning and two quarter-turns in the
evening.
At this point, the orthopedic force should be sufficient,
and activation can be reduced to a more comfortable
one quarter-turn in the morning and one in the evening.

The average activation period is from one
to two weeks, depending on the degree of
maxillary constriction and the resistance of
the patient's maxillofacial structures.
A 2-3mm overcorrection at the molars is
recommended to counteract any relapse.


A. Upper arch before expansion. B. Haastype expander in place.


After full expansion


Once the desired expansion is obtained,
the screw is immobilized by acrylic.
The appliance is kept in place for three
months of retention, which further reduces
the possibility of relapse.


Maxillary Protraction to correct anterior
cross bite
After the first reported successful
protraction of maxilla in children with cleft
lip and cleft palate using Delaire's face
masks (Delaire, Verdon, Kénési 1973), a
number of reports have been published in
the literature.

Face mask can be used with rapid maxillary
expansion appliance where two hooks, each on
one side in premolar-canine region are soldered
to framework of expansion appliance.
When using with fixed orthodontic appliance, two
hooks are soldered and extended from the first
permanent molars to the region of the first
deciduous molars or premolars.

Extraoral elastics applying 450 to 500 gm
of force per side is applied from the hooks
to the extraoral component, the reverse
headgear, at an angle of 10° downward to
the occlusal plane.

The elastic traction are worn 12 to 14
hours daily.

The patient wearing
an orthopedic face
mask appliance.


Pre treatment

Post treatment


Maxillary and
mandibular skeletal
and dental changes
contributing to overjet
correction in unilateral
complete cleft lip and
cleft palate patient
treated with reverse
headgear.


Once the most optimal alignment and
cross bite correction (anterior and
posterior) has been achieved, patient is
ready for secondary bone grafting.
Secondary bone grafting is an important
mean to stabilize the maxillary segments
after expansion and/or protraction
(Rune, 1980)

Secondary bone graft
Goals of secondary bone grafting :
- Closure of vestibular and palatal oral
nasal fistulae .
- Providing sufficient quantity and
appropriate quality of bone to allow
eruption of the permanent lateral incisor
and canine teeth

- Provision of support for the lateral ala of
the nose.
- Provision of suitable bony architecture of
the premaxilla
- Provision of adequate bone stock for
ultimate placement of osseointegrated
implant

Timing of secondary grafting
- Success of secondary alveolar bone grafts
is time dependent.
- Single most important factor deciding the
timing for grafting is developmental status
of dentition In cleft area.


Tooth must erupt through the graft
material because the erupting tooth will
stimulates growth of graft bone, thereby
will maintain vitality of graft material.
When bone graft is performed before
eruption of the permanent canine tooth (910 years), the result is almost always
successful.

The graft material of choice is autogenous
cancellous marrow of the ilium (iliac crest
bone graft), which is packed into the
alveolar cleft defect.


Case example


Criteria of success of bone graft :
(1) long-term preservation of alveolar bone
stock
(2) eruption and periodontal health of the
permanent central incisor, lateral incisor,
and canine teeth,
(3) equality of clinical crown length of the
maxillary permanent central incisor teeth

(4) adequate width of attached gingiva in the
region of the cleft
(5) absence of exposed cementum on teeth
adjacent to the cleft, and
(6) successful placement of osseointegrated
implant.


Various levels of interdental bone present after
secondary bone grafting


If secondary graft fail…….
In spite of great advance in surgical technique,
still there may be failure of secondary graft.
The most important and common cause for this
failure is infection at graft site.
Infection leads to necrosis of graft material
which eventually get resorbed by macrophages
(host’s immune defense)

In general, more the number of times graft is
repeated, failure rate increases proportionally.
The teeth next to the cleft are partially erupted
and are often poorly aligned in the alveolus,
which limits the possibility to place a bone graft
successfully and adequately create a watertight
buccal, palatine, and nasal surfaces closure.


The saliva and bacteria can contaminate
the graft through the periodontal ligament
or through the wound, which produces
partial or total graft failure.


Cesar A. Guerrero (2002) explored the
possibility of distraction osteogenesis in
cleft patients to treat cases where
secondary graft failed.
He named this procedure as Intra oral
bone transport in clefting


Intra oral bone transport in clefting
The possibility of using distraction
osteogenesis to treat alveolar clefts after
the age of 13 years seems attractive to
avoid all the complications related to bone
grafts, especially in failure cases.


Procedure
Patients should undergo orthodontic
treatment and once teeth are aligned and
leveled in segments with heavy
rectangular arch wires, patient is ready for
distraction osteogenesis.


Latency period of 7 days followed by 0.5
mm distraction twice a day.


The advantages of this technique over the
traditional alveolar reconstruction are :
- no need for bone grafts, which involve a
donor site
- minimal surgical time
- natural reconstruction.


- bone height and width that are similar to
the neighboring alveolus with excellent
possibilities for dental implants.
Implant placement ideally should happen
6 to 8 months after the initial surgery.
- Finally, failure rate is minimal.


The disadvantage is long treatment duration
which requires patient cooperation and
close follow-up.


After grafting, a good removable retainer
is placed along with artificial teeth to
replace any missing tooth.
Typically it takes 2-3 years for canine to
fully erupt through the graft. Once canine
erupt, treatment in permanent dentition
starts.

Treatment in permanent dentition
For the patient who has been under the
supervision of a cleft palate team and
received the coordinated care of an
orthodontist and a surgeon, orthodontic
treatment at the time of the permanent
dentition is forecasted.


At the time of permanent dentition :
- A bone graft, if indicated, would have been
placed.
- The lateral incisor and canine on the cleft
side would have erupted through the bone
graft in the line of the cleft.
- potential maxillomandibular disproportions
would have been identified.

Objectives of treatment in permanent
dentition are :
To provide good occlusion
To monitor and if feasible, correction of
any skeletal base discrepancy
To provide good long term retention
 Preparing patient for surgery, if needed

Occlusion considerations
Once all the teeth are erupted, precise
space planning can be done.
Minor space discrepancies can be
resolved without extraction by carefully
advancing the incisors which will improve
patient’s profile also.

First advancing the incisors root tips labially
followed by crown movement frequently make it
possible to achieve sufficient arch length.
Incisor labial root torque and incisor
advancement can promote observable
development of bone in the anterior maxillary
region.
(Delaire 1971, Verdon and salognoc 1977)

But most of the times, space discrepancy
will be severe enough to warrant
extraction of teeth, maxillary or
mandibular, to achieve an acceptable
occlusion


Extractions, although undesirable in the upper
arch, may be necessary because the bony
segments may not be adequate to
accommodate all of the maxillary teeth.
However, if feasible, extractions should be
avoided in the maxillary arch because it can
further increase the undesirable retruded
relationship of the maxillary complex.

Consideration of skeletal base
discrepancy
When maxillary retrusion is mildly
evident, it may be advisable to extract the
mandibular bicuspids to do dentoalveolar
camouflage
(normal overbite, overjet and desirable lip
contour relationships).

But in most of the cases, this dentoalveolar
camouflage may not be sufficient to mask
the underlying skeletal base discrepancy
(class III skeletal base relationship)


Even though maxillary protraction was
undertaken during mixed dentition stage,
still during the later stages of growth,
retrusion of the midface (particularly in the
area of the upper lip) may become
obvious.


Possible reasons for this progressive maxillary
retrusion are
- Inadequate expression of skeletal growth
- Secondary bone grafting may inhibit expression
of any residual growth of maxilla during pubertal
spurt.
- The lower portion of the face may continue to
grow

In these instances, it becomes important
to again undertake maxillary protraction to
improve the facial profile and facial
appearance. (Simonsen 1981, Galletto
1988)


However, Subtenly (1980) claimed that
during later stage of growth, face mask do
little enhancement of skeletal maxillary
development and changes are seemed to
be restricted to maxillary dental arch
advancement.


Therefore in most of the cases, correction
of maxillary skeletal retrusion by
orthopedic means may be beyond the
realm of possibility, and the adjunctive
help of orthognathic surgery is required.


At the completion of treatment in
permanent dentition, long term retention is
required because :
- there is a long time interval (3-5 years)
between completion of orthodontic
treatment and orthognathic surgery.


- Even if no orthognathic surgery is
required, fixed bridge as a retainer can not
be used before completion of late vertical
alveolar growth. (approx. age of 18 years)


-

A partial denture serve effectively as a
long term retainer. It helps to :
stabilize the orthodontic correction,
replace missing teeth,
add sublabial bulk under the upper lip,
it can also obturate sublabial and palatal
fistulas if they remain due to graft failure.

Treatment in adult patients
When the proper maxillomandibular
relationship is not obtained in cleft patients
with conventional orthodontic/orthopedic
methods, orthognathic surgery is
indicated.


It has been estimated that 25% to 60% of
all patients born with complete unilateral
cleft lip and palate require maxillary
advancement to correct the maxillary
hypoplasia and improve aesthetic facial
proportions (Ross,1987)


In some cleft patients who seem to have been
treated successfully by conventional orthodontia
during adolescence, Ross (1987) observed that
there is relapse of anterior and lateral crossbites.
This is not caused by the excessive growth of
the mandible itself, however, but the less sagittal
or vertical growth of the maxillary bone.

Rosa Carolina (2002) recommended that in
these cases, the orthodontist should not prolong
orthodontic treatment but recommend surgical
advancement of the maxilla at the Le Fort I level
as the final stage of treatment.
Sometimes mandibular setback is also required
in patients who have a real mandibular
prognathism.

The timing of orthognathic surgery must be
planned carefully by the surgeon and
orthodontist.
Controversies exist about the timing of the
osteotomies in adolescent patients.


Freihofer (1977) claimed that the only
osteotomies that can be performed in
adolescents without great likelihood of relapse
are anterior maxillary segmental
retropositioning and mandibular
advancement.
Both of these procedures are almost never
done in cleft patients. Hence all orthognathic
surgeries are done in adulthood.

The surgery is usually performed at
approximately 14 - 16 years of age for
females and 17 - 20 years for males when
active facial growth is decreasing to
minimum.


In the past, it was common for the
mandible to be set back to produce a
normal occlusion with the retropositioned
maxilla (this was mainly because of fear of
devitalizing maxilla from the surgery), but
this produced a flat, unaesthetic facial
appearance.


Currently, the standard treatment is a Le Fort I
maxillary advancement.
If the patient has a small chin or if an extensive
setback of the mandible is required, an
advancement genioplasty can be performed
during the same time . If the chin is excessively
long, it can be reduced in vertical height at the
same time (Munro, Salyer, 1990)

Lefort I


Lefort I and mandibular setback
(discrepancy more than 10 mm)


Case report


Distraction osteogenesis as an alternative
to maxillary advancement surgery
Distraction osteogenesis is also an
effective procedure to achieve maxillary
advancement.
Figueroa and Polley (1999, AJODO)
treated 14 patients and concluded that
maxillary distraction technique is a highly
effective treatment modality to manage
cleft related maxillary hypoplasia.

Maxillary distraction osteogenesis in cleft patients
with severe maxillary deficiency is achieved using
Rigid External Distraction (RED) device


A complete Le Fort I osteotomy is performed
Latency period is of 5 – 7 days
Distraction is performed by turning the activating
screw at a rate of 1 mm per day (2 turns).
Once the appropriate amount of distraction was
achieved, the RED system was left in place for 2
to 3 weeks to permit bone consolidation.

Esthetic surgeries (like Rhinoplasty,
cheileoplasty etc.) can be undertaken
once the final picture of facial features is
visible after correcting skeletal bases.


After surgical phase of treatment, general dental
care can be planned in consultation with other
specialist (Prosthodontist, Endodontist,
Periodontist etc)
- All decayed teeth are restored
- In case of poor periodontal health of teeth
(especially near the cleft site), gingival grafts are
placed
- Finally, removable or preferably fixed bridges are
placed to replace missing teeth

Various protocols
Paris, France:
Based on the school of Pierre Petit
Protocol:
- passive presurgical orthopedics
- Soft palate closure at 3 months
- unilateral cleft lip repair done at 6 months
- for bilateral cleft lip, two sides being repaired
separately at 2 months interval (6 month, 8
month)
- hard palate is also closed at age of 6-8 months

- No Orthodontic treatment until mixed
dentition
- Expansion and alignment in anticipation of
SABG at 10 years of age
- Osteotomy followed by rigid fixation to
correct skeletal base discrepancy.
- Lip and nose correction

In UK
Protocol
- Still use active dentofacial orthopedics to
a large extent
- Lip surgery done mostly at 3 moths of
age.
- Palatal surgery at 9 to 12 months

- Expansion during mixed dentition to relieve
functional interference
- Expansion, alignment and reverse head
gear for maxillary protraction at age of 8 9 years
- SABG at of age 9-10 years.

- Complete fixed orthodontic appliances in
the permanent dentition.
- Surgical correction of skeletal discrepancy
in adulthood


Taiwan:
Based on the principles of the Zurich Cleft palate
center
- Passive presurgical orthopedics
- Lip repair done at 3 months of age
- If cleft is large, then a lip adhesion done at 3
months followed by definite closure at 6 months


- Soft plate repair done at 18 to 24 months
and hard plate closure at around 5 to 7
years
- Orthodontic treatment in the deciduous
dentition is not done except in cases with
functional shift of the mandible especially
anterior shift

- Alignment and cross bite correction during
mixed dentition
- SABG preferred before canines erupted
(9-10 years)
- Extra oral orthopedics used in cases of
maxillary retrusion, both during mixed
dentition and early adolescence period
- Surgical correction in adulthood

Oslo, Norway
Established in 1968 by Loennecken,
Harvold and Bohn.
Protocol :
- No presurgical orthopedics
- Closure of cleft lip at 3 months age
- Closure of cleft palate in 18 to 24 months

- Secondary operation (e.g lip lengthening)
if indicated, are performed at age of 5
years.
- No treatment in deciduous dentition
- Mixed dentition preparation to receive a
bone graft
- SABG at 9 to 11 years.

- Permanent dentition treatment started 2 -3
years after graft
- Surgical correction of skeletal base
discrepancy in adulthood


Osaka; Japan
Treatment in 4 phases:
Phase I: presurgical management using
presurgical orthopedics
Phase II: surgical management of lip at 4 - 5
months of age and palate at 14 to 24
months of age.

Phase III: Mixed dentition phase with
emphasis on SABG
Phase IV: Management of orthodontic,
prosthodontic and surgical-orthodontic
treatment


Prague, Czechoslovakia
- Rarely indicate presurgical orthodontics
- Lip repair carried out in 5 to 7 months of
age
- Cleft palate repair at 4 years of age
- Primary alveolar bone grafting done in
selected cases

- Primary dentition – maxillary expansion to
correct functional mandibular shift
- Majority of orthodontic treatment done in
mixed dentition to prepare cleft site for
secondary alveolar bone graft


- Maxillary protraction to correct anterior
cross bite. It maintains configuration of
facial profile and prevent anterior
displacement of mandible.
Acc. to their survey, early orthopedic
therapy reduces the need for orthognathic
surgery by almost 50%.

- Permanent dentition
Final refinement of occlusion
and if required, second phase of maxillary
protraction
- If required, surgical correction of skeletal
base discrepancy in adulthood

Conclusion
There is no perfect method of treating a
cleft patients, patient and his individual
treatment needs must be taken into
account.
Decision should be made along with other
team members who all are responsible for
the well being of the patient form infancy
to adulthood.

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