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Presurgical and Postsurgical Orthodontics in Patients

With Cleft Lip and Palate
Hyoung-Seon Baik, DDS, MS, PhD

Abstract: Patients with cleft lip and palate (CLP) usually have
Patients with CLP usually have CLP closure surgery in
skeletal Class III malocclusion with maxillary deficiency due to the
infancy. The fibrous scar tissue formed by the palate surgery affects
cleft itself and fibrous scar tissue formation caused by the recon- normal forward and downward growth of the maxilla, usually re-
structive surgery. In adult CLP patients with excessive jaw dis- sulting in a vertical and horizontal maxillomandibular relationship
crepancies, orthognathic surgery is often indicated to correct their of skeletal Class III malocclusion with a deficient maxilla. When
functional and esthetic problems. However, CLP patients have dif- comparing the S-N-A and S-N-B angles of the Korean skeletal
ferent inherent structures that may require a strategic approach com- Class III surgical patients in a study by Baik et al2 to those of the
pared with noncleft Class III patients. Main differences in skeletal white skeletal Class III surgical patients in a study by Ellis and
and dental findings of lateral cephalograms between CLP and non- McNamara,2 a majority of the white sample showed an underdevel-
cleft Class III surgical patients are to be demonstrated. Furthermore, oped maxilla, whereas most of the Korean sample showed an over-
a strategic approach with various mechanics in the presurgical developed mandible. The same analysis was performed on CLP
patients who had received orthognathic surgery by Baik et al.3 Ac-
orthodontic stage will be applied to suit the distinct characteristic of
cording to this research, skeletal Class III with underdeveloped
the case. Successful clinical outcome was critically dependent on maxilla and a normal mandible comprised the highest percentage
the close communication among the related specialists. (55%) of CLP patients (Fig. 1). In other words, a large number of
Key Words: Cleft lip and palate, presurgical and postsurgical CLP patients are skeletal Class III with underdeveloped maxilla.
Normal transverse growth of the maxilla is also affected by
orthodontic treatment, skeletal Class III
cleft palate closure surgery that results in constriction of the maxil-
(J Craniofac Surg 2009;20: 1771Y1775) lary arch. The premaxilla appears to be narrower because of con-
genitally missing teeth in the maxillary anterior cleft area (Fig. 2). In
skeletal Class III patients, dental compensation allows labial flaring
of the maxillary anterior teeth, whereas in CLP patients, the max-
T he objective of orthognathic surgery in cleft lip and palate (CLP)
patients coincides to that of typical orthognathic surgery patients
in that both strive for an esthetic face and normal oral function by
illary anterior teeth show normal or even slight lingual crown tipping
caused by tension of the fibrous scar tissue and upper lip closure
(Figs. 3 and 4). The posterior teeth are also tipped palatally (Fig. 5).
improving facial skeletal and dental esthetics as well as achieving Anterior and posterior crossbite is usually observed due to
adequate functional occlusion. Successful presurgical orthodontics maxillary arch constriction, palatal tipping of maxillary posterior
is a prerequisite for successful orthognathic surgery. To accomplish teeth, and lingual crown tipping of maxillary anterior teeth (Fig. 4).
this, it is necessary to understand the skeletal and dental problems Missing tooth in the cleft area, peg lateral incisor or super-
associated with CLP patients and consult related specialists such as numerary teeth, anterior teeth rotation, crowding, and so on are
orthodontists, oral surgeons, prosthodontists, and so on to establish a observed (Fig. 6). The lower anterior teeth are tipped lingually by
treatment plan. Presurgical orthodontics should be carried out dental compensation.
according to the treatment plan to properly position the maxilla,
mandible, and dentition during surgery.
The orthodontic dental problems in CLP patients are anterior
and/or posterior crossbite; uprighting of the upper anterior teeth, Presurgical orthodontic treatment is a process that enables
missing teeth, or supernumerary teeth in the maxilla; upper anterior the upper and lower teeth to occlude in the most adequate and
crowding; abnormal tooth shape or size in the upper anterior teeth;
and so on. The skeletal problems usually appear in the maxilla.1

From the Dental Hospital and Orthodontic Department, College of Dentistry,

Yonsei University, Seoul, Korea.
Received February 26, 2009.
Accepted for publication April 9, 2009.
Address correspondence and reprint requests to Hyoung-Seon Baik, DDS,
MS, PhD, Dental Hospital and Orthodontic Department, College of
Dentistry, Yonsei University, 250 Seongsanno, Seodaemun-gu, Seoul,
Korea 120-752; E-mail:
This article did not require any sources of funding.
The authors declare that they had no financial interests or commercial
associations during the course of this study.
Copyright * 2009 by Mutaz B. Habal, MD
ISSN: 1049-2275 FIGURE 1. Comparison between noncleft Class III surgery
DOI: 10.1097/SCS.0b013e3181b5d644 group and CLP surgery group.

The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009 1771

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Baik The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009

FIGURE 4. In CLP patients (A), upper incisors are uprighted,

whereas in Class III patients (B), the upper incisors are
flared. Anterior and posterior crossbite is observed due to
maxillary arch constriction.

in adults whose midpalatal suture is fused and basal bone expansion

by opening of the midpalatal suture cannot be expected with a typi-
cal RPE appliance.6 Maxillary distraction osteogenesis may be used
FIGURE 2. The upper arch is constricted due to fibrous scar in adult CLP patients to actually move the maxilla anteroposteri-
tissue in the palate. orly with a maxillary distractor.7 This procedure can also be applied
to distract the premaxilla anteriorly, regaining space for the per-
stable position after surgery. The treatment aligns crowded teeth, manent teeth and reestablishing normal arch form (Fig. 10).8
coordinates the maxillary and mandibular arch, and tips the lin- Generally, in CLP patients, more time is needed for this pre-
gually inclined upper and lower incisors labially. surgical orthodontic procedure compared with noncleft patients.
Related specialists should be consulted to either maintain
the space for further conventional prosthetic treatment or an implant POSTSURGICAL ORTHODONTIC TREATMENT
or to bring the posterior teeth forward to close the space caused The purpose of postsurgical orthodontic treatment is to obtain
by the missing tooth or peg lateral incisor. Decisions are made stable occlusion after surgery. Generally, the splint and surgical arch
according to the patient’s condition, but it is wise to make setup wires are simultaneously removed, and round wires are engaged.
models to verify the occlusion when resolving tooth size dis- Occlusal seating is achieved with light elastics.
crepancies and space problems.4 Necessary prosthodontic treatment is performed after de-
In typical skeletal Class III patients, presurgical orthodontic bonding (Fig. 11). In maxillary expansion cases, additional long-
treatment lingually tips the upper incisors because the incisors term retention appliances or prosthetic treatment is recommended
are flared labially. However, in CLP patients, the upper incisors
are uprighted, and labial tipping is required instead.3 The lower
incisors of CLP patients need to be flared labially as is the case in
typical skeletal Class III patients to release the dental compensation
(Fig. 7).
Most cases require expansion in the constricted maxillary
arch for upper and lower arch coordination. The extent of maxillary
constriction should determine the method for maxillary expansion.
A removable appliance with jackscrews or a quad-helix appliance
(Fig. 8) is usually used to expand the maxillary arch in children,
but it can also be applied to patients with little growth remaining in
cases of mild constriction.
In preadolescents or children, orthopedic expansion by rapid
palatal expansion (RPE) (Fig. 9) yields favorable results.5 However,
a mini-implant reinforced RPE should be used for similar results

FIGURE 3. Uprighting of anterior teeth in CLP cases versus

labial tipping of anterior teeth in Class III cases. FIGURE 5. Posterior teeth was tipped palatally as well.

1772 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009 Pre/Postsurgical Orthodontic in CLP

FIGURE 8. A modified quad-helix appliance for arch

expansion and labial tipping of the anterior teeth.
FIGURE 6. Missing teeth are present in the cleft area along
with crowding due to the lack of growth.
because there is a higher tendency of relapse compared with
noncleft patients.

Patient was a 21-year-old woman with left unilateral CLP and
Class III malocclusion. She had a concave facial profile, short
philtrum, anterior and posterior crossbite with midline discrepancy,
crowding in the upper and lower dentition, and severe caries in the
upper left central incisor. Her lateral incisor was missing, and upper
right first premolar had been extracted. Her upper arch was omega
shaped (Fig. 12).7
The S-N-A angle was 73.9 degrees; A-N-B angle, was
j7.3 degrees; Wits, j6.6 mm; and mandibular plane angle,
32.8 degrees, showing a hypodivergent skeletal Class III with an
underdeveloped maxilla (Fig. 13).
The upper incisors were uprighted, whereas the lower incisors
were compensated.
For presurgical orthodontic treatment, extraction of the upper FIGURE 9. Rapid palatal expansion appliance.
left central incisor, relief of crowding, anterior expansion and

FIGURE 10. Miniscrews were placed in the palate for

anchorage reinforcement of the Hyrax (RPE) appliance.
Segmentation was performed distal to the canines for
distraction osteogenesis. After 1 month, the premaxilla was
FIGURE 7. Both the compensated lower incisors and moved anteriorly, and space was made for the ectopically
uprighted upper incisors need be flared labially. erupted maxillary second premolar.

* 2009 Mutaz B. Habal, MD 1773

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Baik The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009

FIGURE 13. Cephalometric analysis.

FIGURE 11. Space caused by the peg laterals was resolved

with porcelain laminates for both lateral and central incisors.

posterior constriction in the maxillary arch, and decompensation of

the lower incisors were planned. Anterior crowding was reduced
by retracting the upper right canine into the extracted first pre-
molar space (Fig. 14).The anterior maxillary arch was expanded
with quad helix, and posterior maxillary arch was constricted with
a precision transpalatal arch simultaneously (Fig. 15).
For surgery, a 2-piece Le Fort I osteotomy, accompanied
by bone grafting, was performed on the maxilla to widen the an- FIGURE 14. Quad helix is used to expand the maxillary
terior area with forward and downward displacement. A prediction anterior arch, and relief of anterior crowding is done
of the surgical change after maxillary 2-piece surgery was made simultaneously.
on a model before surgery (Fig. 16). The mandible was set back
via intraoral vertical ramus osteotomy.7

FIGURE 12. Initial maxillary intraoral photograph. Severe

caries on maxillary right central incisor, missing lateral FIGURE 15. Anterior alignment is almost achieved, and
incisor, extracted space of the left first premolar, and an the posterior teeth are constricted with a precision
omega-shaped maxillary arch are present. transpalatal arch.

1774 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009 Pre/Postsurgical Orthodontic in CLP

FIGURE 16. A model was used to plan the 2-piece surgery and FIGURE 19. Superimpositions before and after surgery.
bone grafting in the maxillary left central incisor area.

In postsurgical orthodontic treatment, the upper left canine was

modified into a lateral incisor, and the first premolar into a canine by
prosthodontic treatment. Due to the forward downward displace-
ment of the maxilla, the philtrum and upper lip were improved
(Figs. 17Y20).
For a successful orthodontic treatment, as always, accurate
diagnosis, proper treatment, and good retention are important.
Treatment planning for CLP patients is essential and requires
special attention.
It is important to consider the dental and skeletal features
of cleft patients along with the distinct characteristics of each
patient. In addition, interdisciplinary cooperation and care between

FIGURE 20. Before (A) and after treatment (B). Note the
improved concave profile.

specialists of orthodontics, oral surgery, prosthodontics, and so on

should begin from the start of treatment planning for an esthetic
and functional outcome. Presurgical and postsurgical orthodontic
FIGURE 17. Maxillary arch after the maxillary left canine was treatment should follow this carefully planned-out blueprint.
modified into a lateral incisor by prosthetic treatment.
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Korean Class III surgical patient and their relationship to plans for
surgical treatment. Int J Adult Orthod Othognath Surg 2000;15:119Y128
3. Baik HS, Yu HS, Jeon JM. A cephalometric comparison of skeletal
Class III malocclusion and cleft lip and palate. Korean J Cleft Lip Palate
4. Proffit WR, White RP. Treatment planning. Surgical Orthodontic
Treatment. Mosby-Year Book Inc., 1999:625Y641
5. Baik HS. Clinical results of maxillary protraction in Korean children.
Am J Orthod Dentofac Orthop 1995;108:583Y592
6. Baik HS. Limitations in orthopedic and camouflage treatment for
Class III malocclusion. Semin Orthod 2007;13:158Y174
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FIGURE 18. Before (A) and after treatment (B). Surg 2000;105:1262Y1272

* 2009 Mutaz B. Habal, MD 1775

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.