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

*Current Treatment of Cleft Lip and Palate*

It is not uncommon for patients to develop a crossbite as the incisors start to erupt. If it is associated with displacement of the lower jaw, tooth wear /fremitus of the opposing dentition than an orthodontist can fabricate a simple upper removable appliance to procline the upper incisors and push them out of an anterior crossbite. Alternatively, a sectional fixed appliance can be used. Care must be taken to ensure that incisors positioned close to the cleft site are not moved out of the alveolar bone

If a dental cross bite is not related to a mandibular shift, it is advisable not to

• long retention period that that will be required which can burn patients

Patients should be seen on a regular basis, usually on a 6 monthly basis to monitor dental development, continue to motivate the family, reinforce oral hygiene and dietary advice and generate a good relationship and rapport with the patient and family. Orthodontic dental records including radiographs, photos and study models should be taken regularly after the eruption of the upper permanent incisors to detect teeth that may be positioned in the cleft area and to ascertain whether there

At this stage a patient may require an autogenous alveolar bone graft which

1. additional bone support for unerupted teeth and teeth adjacent to the cleft

3. support and elevation of the alar base on the cleft side which will help to

4. construction of a continuous arch form and alveolar ridge which in turn will allow the orthodontist to move teeth bodily and upright roots on the cleft side. Additionally, a more continuous archform will enable a prosthodontist/ surgeon to provide a more esthetic and hygienic prosthesis when teeth are

5. stabilization and or repositioning of the premaxilla in patients with a bilateral

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.

as there is typically very thin bone covering these teeth on the cleft side.

• risks of widening a pre-existing oro-nasal communication;

perform any palatal expansion at this early stage due to:

• high risk of relapse due to palatal scarring; and

compliance and impede oral hygiene.

is congenital absence of the lateral incisor.

which will improve their periodontal support;

**2.4 Late mixed dentition**

offers a number of benefits:

missing; and

cleft.

2. closure of oronasal fistulae;

achieve nasal and lip symmetry;

**2.3 Early mixed dentition**

**24**

This generally occurs between 9 and 10 years of age. On rare occasions a graft may be placed at an earlier age to improve the prognosis of a lateral incisor.

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 of methods can be used to achieve expansion which include:


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 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 the new bone.
