**Conflict of interest**

*Current Treatment of Cleft Lip and Palate*

Figueroa [18].

the corrected position.

appliance/distraction osteogenesis.

osteotomies are planned bracket positions should be altered for teeth adjacent to the osteotomy site. A careful evaluation of the cleft site should be made prior to presurgical orthodontics. Snap impressions should be taken periodically to assess whether the presurgical aims have been achieved prior to definitive surgical planning with the maxillofacial/cleft surgeons. The severity of the skeletal pattern will dictate whether a patient will only require a maxillary Le Fort I advancement or bimaxillary surgery. It is important that patients undergo special investigations to determine the effects of any maxillary advancement on the patient's speech prior to planned surgery. Where maxillary advancement is expected to exceed 6 mm, bimaxillary surgery may need to be considered to minimize the risk of developing complications related to speech, maintenance of a vascular supply and development of oronasal fistulas [17]. Alternatively, an orthodontist may be required to carry out internal or external distraction osteogenesis to reduce the impact on speech if big surgical movements are deemed necessary in patients with marked maxillary hypoplasia. Since distraction osteogenesis and midface advancement usually takes place at a rate of 1 mm/ day, changes in velopharyngeal competence can be monitored during the advancement. Distraction can be carried out with internal distraction devices or via the use of a rigid adjustable external distractor which was described in 1997 by Polley and

Compliance with internal distraction devices are better but are limited

in their use. External devices allow the clinician to change the vector of skeletal correction during active distraction. The general principles of distraction involve a period of latency of 5–6 days after a Le Fort I osteotomy is performed after which the appliance is activated at the rate of 1 mm/day. The patient should be monitored closely until the desired outcome is achieved. Inter-arch elastics can be incorporated to help direct the correction. Once the desired correction has been achieved with the distraction device a consolidation period of approximately 8 weeks is required to

Postoperatively, the orthodontist should see the patient weekly to support the surgical treatment via the use of inter-maxillary elastics and settling archwires. Relapse of the surgical correction is more common in the cleft lip and palate patient and is important to monitor post operatively. Surgical techniques such as over correction, complete mobilization of the maxilla followed by rigid fixation, use of bone grafts and or a tension free advancement can help minimize relapse of

On completion of orthodontic treatment all patients should have a retention regime prescribed and should be reviewed for a prolonged period of time since patients may continue to require revision surgery for their soft tissues, pharyngoplasty and complex restorative treatment including bridge, crown or implant treatment. Scarring from previous cleft palate surgery can affect the stability of the corrected malocclusion therefore, if the patients' oral hygiene permits a fixed retainer may be deemed most appropriate coupled with removable Hawley style retainers to help maintain any transverse expansion and general alignment of the dentition. In patients that present with associating craniofacial syndromes the general principles of combined orthodontic and orthognathic surgery still apply. These patients can also be intercepted at an early stage for the provision of a functional

This chapter has focused on the orthodontic aspect of cleft lip palate (CLP) treatment. However, it should be noted that management is multi-disciplinary involving a number of specialists including the oral and maxillofacial surgeons,

allow bone healing prior to carrying out post distraction orthodontics.

**28**

**3. Conclusion**

The author declares no conflict of interest.
