**1.1 Skeletal presentation**

There are well established differences in growth patterns and dimensions among cleft patients. The growth and form of the maxillary arch may be affected in the vertical, antero-posterior and transverse dimensions leading to a dental malocclusion as a result of the severity of the initial cleft deformity and the growth response to the primary surgery [1].

*Antero-posterior sagittal problems:* the cleft lip and palate patient will often present with a Skeletal III base owing to maxillary hypoplasia as a consequence of scar tissue which can restrict the growth of the maxilla in the forwards and downwards direction.

*Transverse problems:* a narrow maxilla is a common finding in affected patients owing to a lack of boney development. Scar tissue from previous palate repair can also constrict the growth of the maxilla in the transverse plane.

*Vertical problems:* vertical deficiency is a common finding and can be coupled with an occlusal cant in the palatal plane, excessive freeway space and altered mandibular posture.
