**2.6 Late permanent dentition**

*Current Treatment of Cleft Lip and Palate*

• align the dentition;

• space closure.

**Figure 2.**

• dental centre-line correction; and

*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

*(a) Pre- and (b) post-expansion upper anterior standard occlusal radiographs demonstrating successful* 

**26**

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 need recountering.

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 mandibular growth.

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 who is treated via orthodontic camouflage.

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

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 Figueroa [18]. 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 allow bone healing prior to carrying out post distraction orthodontics.

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 the corrected position.

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 appliance/distraction osteogenesis.
