**2. Integrated care pathway**

*Current Treatment of Cleft Lip and Palate*

with one or more of the following features:

• presence of natal/neonatal teeth;

• delayed dental eruption;

• enamel hypoplasia;

• deep overbite/openbite;

inheritance patterns.

• centerline discrepancies; and

**1.3 Medical/behavioral presentation**

• presence of supernumerary teeth (20%);

• ectopic eruption or impaction of teeth;

• anomalies in tooth size, e.g. microdontia;

• posterior and anterior cross bites;

• anomalies in tooth morphology, e.g. fused teeth;

• poor oral hygiene leading to caries and periodontal disease;

• dentoalveolar disproportion, e.g. crowding/spacing.

Cleft lip and palate patients may present with numerous behavioral/ medical conditions that can influence orthodontic management. Unfavorable behavioral characteristics can lead to poor oral hygiene and co-operation with orthodontic treatment. Medically, patients may also exhibit neuromuscular anomalies, mental retardation, frequent upper respiratory infections and enlarged adenoids/tonsils. Cleft lip and palate patients may also present with associating syndromes. Associating syndromes with autosomal dominant inheritance include Van der Woude syndrome, Apert syndrome, Treacher Collins syndrome, Cleidocranial syndrome, Ectodermal dysplasia, Pierre Robin sequence and Stickler's syndrome. Roberts syndrome, Christian syndrome and Meckel syndrome are also examples of syndromes with autosomal recessive

As a consequence of the above, cleft patients are seen multiple times by an orthodontist from a young age to monitor their dental development and jaw growth. The majority of patients will require orthodontic intervention at various stages extending from presurgical nasoalveolar molding as a baby to orthodontic preparation before alveolar bone grafting in the mixed dentition to alignment of the upper arch once the permanent dentition is established. Patients may undergo a second course of orthodontic treatment on cessation of jaw growth to either camouflage an

underlying skeletal discrepancy or in preparation for orthognathic surgery.

About 94% of cleft patients have at least one dental anomaly [2] and can present

• congenitally missing teeth especially the upper laterals (50%);

**1.2 Dental presentation**

**20**

Management of the cleft lip and or palate patient is a multi-disciplinary approach involving a number of health care professionals illustrated in **Figure 1**.

All members of the multi-disciplinary team are deemed to be equally important and it is prudent that they all work in tandem with each other to ultimately improve a patient's appearance, speech and function.

The orthodontist is involved in the management pathway at a number of different stages:
