**3. Advantages of CBCT in diagnosing and treatment planning of patients with CLP**

A bony bridge with sufficient height and width is important for successful bone grafting in the alveolar cleft and to guide eruption and movement of permanent teeth [15, 35–37]. The outcome of the procedure is considered satisfactory when a sufficient volume of remodeled bone tissue is obtained; otherwise, the surgery has to be repeated. Thus, volumetric measurements of CBCT images have been using to evaluate the success of alveolar graft outcomes in the current literature [38]. CBCT, an alternative approach to conventional CT that provides similar diagnostic information with much less radiation exposure, avoids the problems associated with traditional 2D imaging such as image enlargement and distortion, structure

**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 radiograph.

orthodontic treatment in deciduous dentition stage. This will need much more retention pro-

Orthodontics in Relation with Alveolar Bone Grafting in CLP Patients

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

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

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,

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.

low-grade inflammation activating proteases that degrade grafted bone [5, 32, 33, 38].

cedures and will impose unnecessary burden of care [5].

orthodonticmovement.

**4.1. Pre-graft orthodontics**

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

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