**1. Introduction**

Cleft lip and palate (CLP) are among the most common of all congenital facial deformities which affect approximately 1 in every 600 newborn babies worldwide [1]. Congenital CL/P can arise in isolation or together with other syndromes. Alveolar cleft (osseous defect in the alveolus of upper jaw) affects approximately 75% of cleft lip and palate patients [2, 3].

The rehabilitation of individuals with CL/P requires interdisciplinary care by centralization of treatment [1, 4].

As the facial cleft affects the whole stomatognathic system, orthodontics is a core element of the overall treatment process. The orthodontist should aim to provide a dentition that

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

functions well and is capable of lifetime maintenance by routine oral hygiene and dental care. However, the underlying skeletal deformity that reflects intrinsic variation and the consequences of surgery severely restricts occlusal change [5].

**4.** To obviate or minimize the need for prosthetic replacement of teeth in the cleft site. **5.** To permit placement of osseointegrated implants into the cleft area when indicated.

Orthodontics in Relation with Alveolar Bone Grafting in CLP Patients

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The long-term success of the alveolar graft is crucial for providing and lifetime maintaining

Postgraft stimulation of maturation through remodeling of the graft is extremely important and is provided primarily by natural tooth eruption. Thus, it is generally agreed that the optimum timing for ABG is in the mixed dentition stage (8–11 years), just before the eruption of the permanent canine in line with the cleft side [10, 13, 16, 19, 22–29]. There is no precise recommended chronological age but, when one-half to two-thirds of the canine root is formed [10]. Canines are mostly the reference teeth because lateral incisors in patient with CLP are frequently absent. However, if lateral incisor is present, earlier bone grafting can be indicated at an age around 7–8 years. It has been found that the success rate is significantly reduced when ABG is performed after eruption of the canine. Resorption of the bone graft is a common situation, and the success of ABG depends on several factors. The periodontal health of the surrounding graft tissues, the experience and ability of the surgeon, and graft material are

The importance of the orthodontist in planning, preparations, and follow-up around ABG procedure is also widely recognized. Successful alveolar bone grafting necessitates a joint

Before treatment, orthodontists should be able to explain the predicted outcome of bone graft-

At that point, diagnostic information is very important for planning pre- and post-orthodontic

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

also shown to be the general factors determining success [13, 19, 20, 23, 30, 31].

orthodontic and surgical involvement pre-, peri-, and postoperatively [10, 32, 33].

**3. Advantages of CBCT in diagnosing and treatment planning of** 

**6.** To stabilize maxillary dental arch.

ing to patients and their parents [34].

management.

**patients with CLP**

**8.** To improve the contour of the alar base.

optimal occlusion and dentofacial esthetics in patients with CLP.

**7.** To facilitate fistula closure.

There are two major factors which effect orthodontic treatment in patients with CLP:

**1.** Facial growth disruption

It is well known that facial growth in patient with CP is disturbed. Besides the intrinsic defect, surgery itself contributes to further disruption [3, 6]. A significant feature of facial growth in repaired CP patients is that the maxilla fails to grow at the same rate as the mandible during the adolescent growth spurt. Progressive midfacial retrusion is usually seen by the mid- to late teens. The results of the facial growth studies revealed the general characteristics of the individuals with UCLP: a short retrusive maxilla and vertical elongation of the anterior face, a retrusive mandible, and a reduction in posterior face height [6–9].

**2.** Alveolar bone deficiency

Lack of the alveolar bone may give rise to a variety of problems, including oronasal fistula, fluid reflux, speech pathology, impaired tooth eruption, lack of bone support for the anterior teeth, dental crowding, periodontal recession and eventual loss of teeth, and maxillary and facial asymmetry. Alveolar defect also limits orthodontic treatment and/or prosthodontic rehabilitation [10–12].

Thus, orthodontic treatment for children with cleft should aim to achieve an optimal occlusion and dentofacial esthetics within the constraints imposed by the underlying skeletal pattern [5].

The integration of orthodontics into the overall treatment of CLP starts any point between birth and end of the teens and highly related to surgical procedures, including lip repair, alveolar bone grafting, distraction, and orthognathic surgery [5].

This chapter reviews current orthodontic approaches in relation with alveolar bone grafting (ABG) in nonsyndromic cleft patients.
