**4. Mixed dentition stage (phase I orthodontic treatment)**

Orthodontic treatment of patients with CLP takes much more time (is more extensive) than routine treatment because of the underlying skeletal pattern. There is no need to attempt

**Figure 3.** Malpositioned lateral incisor in the cleft area should be extracted 3–4 weeks before ABG.

orthodontic treatment in deciduous dentition stage. This will need much more retention procedures and will impose unnecessary burden of care [5].

Monitoring eruption of the teeth is important by the age 6–7.Radiographic evaluation is needed at the age of 8–9 (after eruption of upper incisors) to detect any possible teeth positioned in the cleft area and to see if lateral incisor is missing or not. If lateral incisor is present, earlier bone grafting can be planned. It is often advisable that any supplemental, deciduous teeth and also malformed and/or malpositioned lateral incisors in the cleft area should be extracted 3–4 weeks before surgery that permits healing of the mucosa (**Figure 3**). Thus, CBCT 6–8 months before ABG is recommended for detailed evaluation of bony support and position of the cleft-related teeth. This time frame will provide enough time to accomplish all necessary pregraft preparations such as tooth extraction and/or orthodontic tooth movement on time and not to delay bone grafting. Sometimes an additional CBCT just before the grafting might be needed to assess the root position of the cleft-related teeth after orthodonticmovement.

#### **4.1. Pre-graft orthodontics**

overlap, positional problems, and limited number of identifiable landmarks (**Figure 1**). It has been used to quantify the average volume of the graft, location of the bone loss, and periodontal bone support of the cleft-adjacent teeth. CBCT-derived volumetric assessment of alveolar grafts has been reported as a reliable method [24, 29, 37, 39, 40] (**Figure 2**). The success rate of an alveolar graft has been found to be significantly lower with volumetric evaluation than that

**Figure 1.** Superimpositions on the 2D imaging might led to misdiagnosis. (a) Grafted area seems to be filled successfully on the pantomograph; (b) axial view of the CBCT image shows that graft is not successful as seen on the panoramic

Orthodontic treatment of patients with CLP takes much more time (is more extensive) than routine treatment because of the underlying skeletal pattern. There is no need to attempt

with conventional radiographic imaging [39, 41, 42].

radiograph.

160 Current Approaches in Orthodontics

**4. Mixed dentition stage (phase I orthodontic treatment)**

**Figure 2.** The precise volume and density can be measured by using various software.

Presurgical orthodontics plays an important role in correcting misaligned incisors or repositioning displaced maxillary alveolar segments. Severe central or canine inclination toward the cleft defect can also interfere with cleft mucoperiosteal dissection. Presurgical orthodontics allows the surgeon better access for placement of the graft and closure of the soft tissue (**Figure 4**). Furthermore, correction of central incisor rotation and inclination prior to SABG enables patients to achieve better oral hygiene and prevents plaque formation. This can therefore prevent chronic, low-grade inflammation activating proteases that degrade grafted bone [5, 32, 33, 38].

One of the presenting problems which occurs early in both unilateral and bilateral clefts is the anteroposterior malpositioning of the incisors. If the anteroposterior malpositioning of the incisors is not corrected, lingual lock of the anterior teeth will further inhibit the development of the maxilla. The proper overjet relationship will allow appropriate growth of the maxilla [19]. By age 7–8, incisor alignment and correction of anterior crossbite can be provided to maximize the forward development of the maxillary dentoalveolar process. However, orthodontic movement of maxillary anterior teeth must be done with great caution because of the closeness of the roots to the bony defect. A very thin bony covering of the central incisor next to the cleft site is a common feature. Often there is just a lamina dura with no cancellous bone.

facility during surgery. If possible, transverse expansion can be combined with the correction of incisor irregularities. In the mixed dentition stage, arch expansion is very important because this process also normalizes the morphology and induces eruption of the canine into

**Figure 5.** Various types of expanders for maxillary expansion. (a) TPA with lateral expansions, (b) quad helix, (c) NiTi

Orthodontics in Relation with Alveolar Bone Grafting in CLP Patients

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Several types of expanders have been used, and there is no universal protocol for maxillary expansion prior to secondary alveolar bone grafting (**Figure 5**). Both slow maxillary expan-

SME using the quad helix or its variations is frequently used for segmental repositioning as selective expansion anteriorly is required [5]. It has been shown that slow expansion forces are apparently already sufficient to allow a skeletal expansion of the maxilla in complete cleft palate patients [45, 47, 48]. There were *no differences* found between the dentoalveolar effects

RME with Haas type or hyrax expanders is also widely used for correcting the maxillary constriction. Asymmetric expansions were found by several authors [46, 48–53]. Isaacson and Murphy reported no correlation between the cleft location and the relative amount of lateral movement of each maxillary segment, emphasizing that RME laterally repositioned the maxillary segments in an unpredictable manner [49]. For greater amount of anterior displacement of the maxilla, fantype or double-hinged RPE expanders have been

According to our clinical experience, there is usually no need for RPE in patients with UCLP. Quad helix or TPA with lateral expansions can solve the problem. However, in some patients with BCLP, significant constriction of the segments necessitates RPE. Thus, patient

sion (SME) and rapid maxillary expansion (RME) have been advocated [5, 47, 48].

the symmetrical maxillary arch [10, 13, 19, 46].

of SME and RME in patients with BCLP [45, 47].

advocated [54].

expander, and (d) hyrax.

selection is important in this issue.

**Figure 4.** Severe canine inclination toward the cleft defect should be corrected before ABG. (a,b,c) initial views, a. intraoral, b. 3D image c. panoramik radiograph of the patient. (d,e) orthodontic traction of the cleft related canine. (f,g) pregraft 3D image and panoramic radiograph.

The incisor should not be bodily uprighted before successful ABG because of the possibility of bone loss and fenestration of the thin cortical lamina [10, 43].

#### **4.2. Transverse expansion**

Constriction of maxillary segments is a very common situation in patients with cleft palate. As the individuals with complete cleft lip and palate do not have midpalatal suture, constriction occurs mostly by the rotation of the lateral segment(s) inward, toward bony defect. Both the absence of the midpalatal bone and the soft tissue traction produced by lip and palate repair promote arch constriction [5, 44, 45].

Significant segmental displacement requires pre-bone graft expansion to rotate the lateral segment(s) outward, facilitate placement of the graft, and provide the surgeon working

**Figure 5.** Various types of expanders for maxillary expansion. (a) TPA with lateral expansions, (b) quad helix, (c) NiTi expander, and (d) hyrax.

facility during surgery. If possible, transverse expansion can be combined with the correction of incisor irregularities. In the mixed dentition stage, arch expansion is very important because this process also normalizes the morphology and induces eruption of the canine into the symmetrical maxillary arch [10, 13, 19, 46].

Several types of expanders have been used, and there is no universal protocol for maxillary expansion prior to secondary alveolar bone grafting (**Figure 5**). Both slow maxillary expansion (SME) and rapid maxillary expansion (RME) have been advocated [5, 47, 48].

SME using the quad helix or its variations is frequently used for segmental repositioning as selective expansion anteriorly is required [5]. It has been shown that slow expansion forces are apparently already sufficient to allow a skeletal expansion of the maxilla in complete cleft palate patients [45, 47, 48]. There were *no differences* found between the dentoalveolar effects of SME and RME in patients with BCLP [45, 47].

The incisor should not be bodily uprighted before successful ABG because of the possibility

**Figure 4.** Severe canine inclination toward the cleft defect should be corrected before ABG. (a,b,c) initial views, a. intraoral, b. 3D image c. panoramik radiograph of the patient. (d,e) orthodontic traction of the cleft related canine. (f,g)

Constriction of maxillary segments is a very common situation in patients with cleft palate. As the individuals with complete cleft lip and palate do not have midpalatal suture, constriction occurs mostly by the rotation of the lateral segment(s) inward, toward bony defect. Both the absence of the midpalatal bone and the soft tissue traction produced by lip and palate repair

Significant segmental displacement requires pre-bone graft expansion to rotate the lateral segment(s) outward, facilitate placement of the graft, and provide the surgeon working

of bone loss and fenestration of the thin cortical lamina [10, 43].

**4.2. Transverse expansion**

162 Current Approaches in Orthodontics

promote arch constriction [5, 44, 45].

pregraft 3D image and panoramic radiograph.

RME with Haas type or hyrax expanders is also widely used for correcting the maxillary constriction. Asymmetric expansions were found by several authors [46, 48–53]. Isaacson and Murphy reported no correlation between the cleft location and the relative amount of lateral movement of each maxillary segment, emphasizing that RME laterally repositioned the maxillary segments in an unpredictable manner [49]. For greater amount of anterior displacement of the maxilla, fantype or double-hinged RPE expanders have been advocated [54].

According to our clinical experience, there is usually no need for RPE in patients with UCLP. Quad helix or TPA with lateral expansions can solve the problem. However, in some patients with BCLP, significant constriction of the segments necessitates RPE. Thus, patient selection is important in this issue.
