**6.1. Maxillary space management choice**

In patients with CLP, the lateral incisor is missing in about 50% of cases in the permanent dentition. There are two options when maxillary lateral incisors are absent: space closure or space preservation [5].

The success of the bone graft is the determinant factor for this choice. When bone graft is properly done before the eruption of the permanent canine, canine can simultaneously migrate Orthodontics in Relation with Alveolar Bone Grafting in CLP Patients http://dx.doi.org/10.5772/intechopen.80853 165

**5. Postgraft stabilization**

164 Current Approaches in Orthodontics

**6. Postgraft orthodontics**

impaction [5, 32].

tion to the graft.

premaxillary arch [19].

space preservation [5].

The quad helix and/or stabilizing archwire used in BCLP may be removed during the bone grafting procedure for improved surgical access, but these appliances should be replaced

As the bone grafting alone cannot be relied upon to maintain the expansion, a simple palatal

Stabilizing a mobile premaxilla with orthodontic arch wire is needed in patients with complete BCLP. Typically the arch wires will be removed during surgery and replaced at the end

If the graft is done at proper time, before eruption of the cleft-related permanent canine, observation of the permanent dentition is generally all that is necessary. The status of cleft side unerupted teeth does need careful monitoring [5]. Physiologic eruption of the adjacent canine will provide enough stimulation for the alveolar graft. Sometimes orthodontic traction might be needed if the position of the canine is not appropriate for spontaneous eruption. High degrees of canine inclination indicate risk for altered eruption and

If graft is done at age 7–8, correction of incisor irregularities provides also favorable stimula-

Orthodontic movement of the cleft-adjacent teeth in the direction of the grafted bone can be instituted at an average of 3 months after the bone grafting, if needed. Combined interceptive bone grafting and orthodontic treatment at an early age avoid more extensive prolonged

It has been recommended not to delay orthodontic treatment more than 6 months after grafting, in cases in which an a-p crossbite or a residual transverse posterior crossbite exists. Oneto two year delay in stimulation of the ABG of the premaxilla (by orthodontic treatment) can lead to serious postoperative problems. Where there is no stimulation of the graft, there tends to be "locking" or lingual collapse of the maxillary central incisors and collapse of the

In patients with CLP, the lateral incisor is missing in about 50% of cases in the permanent dentition. There are two options when maxillary lateral incisors are absent: space closure or

The success of the bone graft is the determinant factor for this choice. When bone graft is properly done before the eruption of the permanent canine, canine can simultaneously migrate

before the patient leaves the operating room and left in place for 3 months.

arch would be advisable until the permanent dentition has erupted.

of the operation to provide retention [5, 10, 19].

treatment later in the patient's life [5, 13, 19, 34].

**6.1. Maxillary space management choice**

**Figure 6.** Space closure with canine substitution in patient with successful ABG. (a-d) intraoral occlusal views of the case. a. pre-graft, b. post-graft, c. after eruption of the canine, d. levelling of the upper dentition. (e-h) panoramic radiographs of the case. a. pre-graft, b. post-graft, c. eruption of the canine, h. levelling of the upper arch.

into the newly formed bone and increases its vertical height. Maintaining the alveolar bone height in the cleft area is important to prevent long-term complications, such as gingival retractions and periodontitis [32, 33].

Moreover, the natural dentition has the best prognosis for long-term health of the dentition. Thus, space closure with the canine substitution should be the first treatment choice for patients with CLP [5, 32, 33] (**Figure 6**). The functional stress imposed by orthodontic treatment influences the volume and prevents resorption of the grafted bone. Higher grafting success was found in the case of space closure than in the case of space openings [5, 33].

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 prosthesis might be needed.
