**7. Management of maxillary deficiency in growing cleft patients**

Hypoplastic maxilla and progressive midface retrusion are typical characteristics of patients with CLP.

Therefore, maxillary protraction (MP) has been frequently applied in the orthodontic treatment of growing patients with cleft lip and palate to improve the maxillomandibular relationship, occlusion, and facial esthetics. Optimal timing for initiating maxillary protraction for non-cleft children is shown as in the early mixed dentition before age 10. Early mixed dentition is favored over late, because of the closure of the sutures of the nasomaxillary complex [55].

However, SABG is optimally carried out between 9 and 11 years, and there is no consensus on the treatment sequencing of maxillary protraction and SABG in patients with CLP.

Two studies of three-dimensional finite element analysis suggested the advantage of SABG before maxillary protraction [55–57].

In a recent clinical study, short-term results showed that facemask therapy after alveolar bone grafting led to enhance maxillary skeletal advancement and minimize mandibular clockwise rotation more than those in the ungrafted group.

Maeda-lino found that the root lengths of U1 were comparatively short on the cleft side in patients with UCLP treated with MPA before SABG. Thus, they concluded that orthodontic force exerted by the MPA before SABG might result in short dental roots [58].

**7.1. Patients with no to mild skeletal discrepancy**

after orthognatic surgery.

lateral cephalogram.

Providing proper overjet relationship at the early mixed dentition by correcting lingual lock of the anterior teeth using either removable or fixed appliances will be sufficient to maximize the forward development of the maxillary dentoalveolar process. Facemask can be a valuable source of anchorage for advancing posterior teeth during space closure after SABG [5, 19].

**Figure 8.** Cephalometric radiographs of the patient after facemask therapy between 10 and 19 years of age and after orthognathic surgery. (a) age 10, after face mask therapy, (b) age 14, follow-up, (c) age 19, ğre-orthogntic surgery, (d)

**Figure 7.** Face mask application using bonded hyrax in patient with BCLP. (a) extraoral view of the patient. (b) initial

Orthodontics in Relation with Alveolar Bone Grafting in CLP Patients

http://dx.doi.org/10.5772/intechopen.80853

167

Moreover, it has been advocated that protraction of severely retruded cleft maxilla, even at an early stage, does not provide lasting skeletal benefit. Its effect in individual cases with CLP is difficult to predict, and many patients require orthognathic surgery after MP treatment [5, 59, 60] (**Figures 7** and **8**). Thus, explanation of the expected effects and associated problems should be given to the patients and parents before MP treatment.

However, in patients with severely impaired maxillary growth, multiple missing teeth, and/ or failure of bone graft, orthodontic space closure may not be feasible, and some form of

Extraction of maxillary teeth may be required in UCLP in non-cleft quadrant, either because of crowding or to allow correction of the dental midline. As the second premolar is frequently malformed, it is the most commonly removed tooth. In some patients removal of the non-cleft lateral incisor allows the rapid restoration of the symmetry. However, this should be consid-

In the lower arch, the absence of the second premolars is frequent and should be assessed

Extraction of the lower teeth to compensate class III skeletal pattern should be avoided in the

Hypoplastic maxilla and progressive midface retrusion are typical characteristics of patients

Therefore, maxillary protraction (MP) has been frequently applied in the orthodontic treatment of growing patients with cleft lip and palate to improve the maxillomandibular relationship, occlusion, and facial esthetics. Optimal timing for initiating maxillary protraction for non-cleft children is shown as in the early mixed dentition before age 10. Early mixed dentition is favored over late, because of the closure of the sutures of the nasomaxillary complex [55].

However, SABG is optimally carried out between 9 and 11 years, and there is no consensus on

Two studies of three-dimensional finite element analysis suggested the advantage of SABG

In a recent clinical study, short-term results showed that facemask therapy after alveolar bone grafting led to enhance maxillary skeletal advancement and minimize mandibular clockwise

Maeda-lino found that the root lengths of U1 were comparatively short on the cleft side in patients with UCLP treated with MPA before SABG. Thus, they concluded that orthodontic

Moreover, it has been advocated that protraction of severely retruded cleft maxilla, even at an early stage, does not provide lasting skeletal benefit. Its effect in individual cases with CLP is difficult to predict, and many patients require orthognathic surgery after MP treatment [5, 59, 60] (**Figures 7** and **8**). Thus, explanation of the expected effects and associated problems

the treatment sequencing of maxillary protraction and SABG in patients with CLP.

force exerted by the MPA before SABG might result in short dental roots [58].

should be given to the patients and parents before MP treatment.

carefully where extractions are necessary to relieve lower incisor crowding.

**7. Management of maxillary deficiency in growing cleft patients**

prosthesis might be needed.

ered when compliance with space closure is assured [5].

**6.2. Extraction choice**

166 Current Approaches in Orthodontics

early teens.

with CLP.

before maxillary protraction [55–57].

rotation more than those in the ungrafted group.

**Figure 7.** Face mask application using bonded hyrax in patient with BCLP. (a) extraoral view of the patient. (b) initial lateral cephalogram.

**Figure 8.** Cephalometric radiographs of the patient after facemask therapy between 10 and 19 years of age and after orthognathic surgery. (a) age 10, after face mask therapy, (b) age 14, follow-up, (c) age 19, ğre-orthogntic surgery, (d) after orthognatic surgery.

#### **7.1. Patients with no to mild skeletal discrepancy**

Providing proper overjet relationship at the early mixed dentition by correcting lingual lock of the anterior teeth using either removable or fixed appliances will be sufficient to maximize the forward development of the maxillary dentoalveolar process. Facemask can be a valuable source of anchorage for advancing posterior teeth during space closure after SABG [5, 19].
