**2.4 Late mixed dentition**

At this stage a patient may require an autogenous alveolar bone graft which offers a number of benefits:


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the new bone.

**2.5 Early permanent dentition**

graft after a minimum of 6 months;

• relieve crowding;

*Orthodontic Management of Cleft Lip and Palate Patients*

This generally occurs between 9 and 10 years of age. On rare occasions a graft may

Most cleft patients will present with a narrow V-shaped upper archform hence, prior to receiving an alveolar bone graft expansion of the segments that make up the upper archform may be required by the orthodontist to improve access for surgery to allow maximum boney infill. Prior to starting active expansion an upper anterior standard occlusal radiograph, long cone periapical radiograph or CBCT of the cleft site should be considered to assess the volume of bone. There is no universal protocol for maxillary expansion prior to secondary alveolar bone grafting and a number

1. removable appliances—these can be used to correct an anterior cross bite and simultaneously expand and correct a posterior cross bite but are less popular for cleft patients as removable appliances can impede existing speech problems;

2. rapid maxillary expansion appliances—a number of designs can be used pending the type and amount of expansion that is required. The Hyrax appliance is useful when parallel expansion is required. Fan expansion screws can be used

3. a fixed quad-helix/tri-helix appliance—these appliances provide controlled

The expansion once commenced, should be monitored closely. The cleft surgeon and orthodontist must work in tandem to determine the anatomical limits of presurgical maxillary expansion. This is prudent to avoid overexpansion and development of an oronasal fistula that is beyond the limits of surgical closure. An upper anterior standard occlusal radiograph should be taken and reviewed by the orthodontist and cleft surgeon to assess whether enough expansion has taken place (**Figure 2**). Thereafter, the archform should be maintained with a simple upper removable appliance or trans-palatal arch. It is important to note that any primary teeth in line of the cleft should usually be removed a minimum of 3 months in advance of any planned alveolar bone graft to allow repair of the soft tissues. Supernumerary teeth can be extracted closer to the time of alveolar bone graft.

Three to six months post ABG, a postoperative CBCT or upper anterior standard

• facilitate the eruption of the canine tooth with or without surgical exposure and bonding of the tooth if it has failed to erupt through the alveolar bone

occlusal radiograph should be obtained to confirm the outcome of the surgery which is generally considered satisfactory when sufficient volume of remodeled bone tissue is present. The orthodontist should monitor the developing dentition and eruption of the canine for a minimum of 3–6 months before moving teeth into

Orthodontic treatment at this stage may be conducted to:

• attempt correction of a developing Skeletal III relationship;

be placed at an earlier age to improve the prognosis of a lateral incisor.

of methods can be used to achieve expansion which include:

when larger expansion is required anteriorly; and

force application.

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

The timing of a secondary alveolar bone graft largely depends on dental development than chronologic age. This usually takes place prior to the eruption of the upper permanent canine tooth when its root is approximately two-thirds formed.
