**2.5 Early permanent dentition**

Orthodontic treatment at this stage may be conducted to:


### **Figure 2.**

*(a) Pre- and (b) post-expansion upper anterior standard occlusal radiographs demonstrating successful expansion prior to a planned alveolar bone graft.*


Comprehensive correction of the malocclusion via orthodontic camouflage will be dictated by the extent of the underlying skeletal discrepancy and the likely effect of any future lower jaw growth. In cleft lip and palate patients the mandible is often unaffected and will grow normally, however, growth of the maxilla is often restricted in the forwards and downwards direction compared to the non-cleft patient [12]. Scar tissue from previous hard palate repair is thought to disturb growth of the maxilla leading to a short/hypoplastic maxilla and a Class III malocclusion [13]. Fibrosis can strip the periosteum and also affects antero-posterior, vertical and transverse growth. One option is to consider orthopedic correction during the early mixed dentition at ~7–9 years of age. This treatment option is generally limited to patients with a maximum negative overjet of 4–5 mm [14]. Orthopedic correction of a short maxilla in the cleft lip and palate patient would involve the use of protraction facemask therapy with forces in the range of 300–500 grams per side over 10–12 hours/day. Stability of this treatment is questionable due to counter pressure of a tight lip on the maxilla and scarring in pterygomaxillary region after extensive tissue mobilization for palatal closure. Reported success of this treatment varies with one study reporting an average of only 1.3 mm of maxillary protraction in Class III patients with unilateral cleft lip and palate [15]. Success rates reduce as

**27**

*Orthodontic Management of Cleft Lip and Palate Patients*

the patient ages. Long term results of early protraction appear to be only temporary which often have to be readdressed during late adolescence with retreatment [16]. To that end, if the patient is growing unfavorably and developing a significant class III incisor relationship and skeletal pattern then fixed appliance treatment should also be delayed until the patient has completed their jaw growth to coincide with any planned orthognathic surgery. However, fixed appliance orthodontic treatment can be carried out and limited to the upper arch to relieve crowding, align the dentition, dental center-line correction and or facilitate the eruption of canine teeth whilst lower jaw growth is monitored, and in attempting to achieve the above objectives extraction of a maxillary premolar or lateral incisor on the non-cleft side

Once the patient reaches adulthood the cleft patient should be reassessed with full diagnostic records. At this stage the outcome of previous orthodontic, hard or soft tissue surgery and speech therapy should be examined. If a cleft patient in the permanent dentition presents with no skeletal deformity then management of the dental malocclusion is not dissimilar from that of a non-cleft patient. For example patients with isolated clefts of the lip and alveolus or clefts of the soft palate may be amenable to fixed orthodontic treatment alone. The dental malocclusion may be limited to mild anterior or posterior crossbites, rotated teeth and missing lateral incisors in the cleft site. Mild crossbites can be managed through archwire expansion/quadhelix appliance. Where a patient presents with missing lateral incisors a decision needs to be made with a prosthodontist to either close the spacing or redistribute space for a future prosthetic replacement. This decision is usually based on patient wishes, esthetics, position of the molar teeth and dental centerline and financial considerations. If a decision is made to open space, during active orthodontic treatment the space can be maintained with the use of a pontic tooth that contains a bracket and is ligated to the archwire. Once facial growth is complete, a single tooth implant can be placed. If space closure is planned the permanent canine will need recountering on the incisal, labial, mesial, distal and lingual surfaces either during or after active orthodontic treatment. A lateral incisor bracket should be bonded on the canine tooth more gingivally, to bring the gingival margin down and level to the adjacent incisor. Additionally, the first premolar which will adopt the canine position will also

Patients presenting with mild skeletal discrepancies, minimal concerns about facial esthetics and no strong family history of mandibular excess can also be treated via orthodontic dental compensation. However, patients should be warned that any correction may be compromised if the patient continues to exhibit man-

Most patients will present with a moderate to significant Class III incisor and skeletal relationship due to maxillary hypoplasia however, the need for orthognathic surgery will depend on patient wishes/concerns as well as function and esthetics. Patients who are happy to consider orthognathic treatment should be planned for carefully with an Oral and maxillofacial surgeon or plastic reconstructive surgeon. Timing is crucial. A restorative specialist may be involved to examine the need for implants, crown or bridgework as part of the overall plan as with the cleft patient

Presurgical fixed appliance treatment is carried out by the consultant orthodontist to decompensate the labial segments, level and align the arches and coordinate the dental arches for a stable occlusal outcome. Where multiple segment maxillary

*DOI: http://dx.doi.org/10.5772/intechopen.90076*

may be indicated.

need recountering.

dibular growth.

who is treated via orthodontic camouflage.

**2.6 Late permanent dentition**

*Orthodontic Management of Cleft Lip and Palate Patients DOI: http://dx.doi.org/10.5772/intechopen.90076*

the patient ages. Long term results of early protraction appear to be only temporary which often have to be readdressed during late adolescence with retreatment [16]. To that end, if the patient is growing unfavorably and developing a significant class III incisor relationship and skeletal pattern then fixed appliance treatment should also be delayed until the patient has completed their jaw growth to coincide with any planned orthognathic surgery. However, fixed appliance orthodontic treatment can be carried out and limited to the upper arch to relieve crowding, align the dentition, dental center-line correction and or facilitate the eruption of canine teeth whilst lower jaw growth is monitored, and in attempting to achieve the above objectives extraction of a maxillary premolar or lateral incisor on the non-cleft side may be indicated.
