CLP Seminar

Dept. of Orthodontics & Dentofacial Orthopedics , V.Y W. S.
Dental College,AMARAVATI
SEMINAR ON
THE ROLE OF ORTHODONTIST IN

MANAGEMENT OF CLEFT LIP & PALATE
PATIENTS
Guided by- Presented By-

Dr. A. A. Verulkar
Dr. S. B. Wankhade Dr. Niyati Potode
Dr. R. N. Advani P.G. Part III
Dr. R . A. Lohakpure 17/07/2019
Dr. Shweta Kolhe
CONTENTS
INTRODUCTION
HISTORY
MULTIDISCIPLINARY APPROCH
DIFFERENT CLEFT PROTOCOL
MANAGEMENT OF CLEFT LIP AND PALATE
 INFANT ORTHOPEDICS
 TREATMENT IN MIXED DENTITION
 TREATMENT IN PERMANENT DENTITION
SURGICAL ORTHODONTICS
DISTRACTION OSTEOGENESIS
VELOPHARYNGEAL INCOMPETENCE
RECENT ADVANCES
CONCLUSION
REFERENCES
INTRODUCTION
CLEFT PALATE-
a furrow in the palatal

WHAT’S WRONG
vault WITH ME?
or
a breach in the continuity

of palate
HISTORY
1561- PAREA a French surgeon was the first one who used obturator .
The team concept was not formalized until the 1940s, but the literature
starting in 1915 reflects the influence of interdisciplinary
management with orthodontists and their colleagues
and collaborators..
Katherine W. L. Viga and Ana M. Mercadob Overview of orthodontic care for children with cleft lip and palate, 1915-2015
Am J Orthod Dentofacial Orthop 2015;148:543-56)
1915
International Journal of Orthodontia
1919-1921
International Journal of Orthodontia and Oral Surgery
1922-1932
International Journal of Orthodontia, Oral Surgery and Radiology
1933-1935
International Journal of Orthodontia and Dentistry for Children
1938-1947
American Journal of Orthodontics and Oral Surgery
1948-June 1986
American Journal of Orthodontics (AJO)
July 1986-present
American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO)
 In 1938 Herbert Cooper founded the first clinic in the United
States .- “facial cripples”
 By 1943, the American Cleft Palate Association (ACPA) was

established.
1964 January - The Cleft Palate Journal, launched , is the official

publication of the ACPA
currently published as the Cleft Palate- Craniofacial Journal.
Katherine W. L. Vig and Ana M. Mercadob Overview of orthodontic care for children with cleft lip and palate, 1915-2015
The Northwestern University CLP Institute introduced the concept of
coordinated and integrated treatment plans in a team approach around a
conference table.
The original cleft palate teams in the 1950s represented 3 main
disciplines: -
Surgery,
Speech Pathology,
Orthodontics.
Katherine W. L. Vig and Ana M. Mercadob Overview of orthodontic care for children with cleft lip and palate, 1915-2015
By the 21st century, the team embraced multiple specialties
Pediat
-rician
Genetic Pedo
scientist -dontist
Speech OrthOrt
hodontis
pathologi todontis
-st t
patient
Psychia Oral
-trist surgeon
Plastic Prostho
surgeon -dontist
Social
ENT
worker
Craniofacial orthodontist
The American Dental
Association ( ADA)-
“ Area of orthodontics that
treats patients with congenital
and acquired deformities of
the integument and its
underlying musculoskeletal
system within the
maxillofacial area and
associated structures” (CO)
Gandedkar NH, Koo CS, Chng CK, Por YC, Yeow VK, Sng KW. Role of the “craniofacial orthodontist” in a
craniofacial team”. J Indian Orthod Soc 2018;52:S4-13.
Prenatal period: importance of
early diagnosis
Ultra sonography
Three dimensional
ultrasonic imaging
Advantages of Prenatal diagnosis
1. Psychological preparation of
parents and caregiver
2. Preparation for neonatal care and
feeding.
3. Opportunity to investigate for
other structural or chromosomal
abnormalities.
4. Possibility for fetal surgery .
5. Customized surgical treatment
plan by the plastic surgeon.
Disadvantages
1. An emotional disturbance and

high maternal anxiety after
prenatal diagnosis
2. Families choosing to terminate
the pregnancy even in the
absence of other malformation.
3. Perceived burden.
4. Expectation of recurrence.
5. Religion and cultural belief.
Different treatment protocols
NETHERLAND PROTOCOL-
a) Presurgical orthopedic treatment
appliance – birth to 1½ years
b) Lip closure at -5-6 months
c) 2 stage palatal closure – soft
palate 12-18 months, hard palate
6-9 years
d) Bone grafting to alveolar cleft
ZURICH PROTOCOL
a) Passive plates worn for 16-18 months
b) Plate changed every 6 months
c) Reduction of gingival side of the plate
every 3-8 weeks
d) lip closure -6 months
e) Soft palate -18 months
f) Hard palate -4.5 years
OSLO PROTOCOL- Established in 1968 by Loennecken,
Harvold and Bohn.
a) Does NOT follow preoperative orthopedics.
b) Milard lip repair at age of 3 months.
c) In cases with associated cleft of the alveolus and palate , a
cranial base single layer vomer flaps sutured under the
alveolus palate periostium at the time of lip repair.
Goals and objectives of treatment are to :
1. Close vestibular and palatal oronasal fistula

2. Restore physiologic continuity of the dental arch to
enable oral and dental health to be maintained
3. Provide bone for stability and continuity of the dental
arch (bone grafting)
4. Allow eruption of the permanent teeth or placement of
dental implants through bone graft.
5. Provide support for the lateral ala of the nose.
6. Orthodontic alignment of teeth.
7. Facilitate nasolabial muscle and soft tissue
reconstruction.
8. Establish functional nasal airway.
9. Provide support for the lip.
10. Prevent tooth loss caused by lack of periodontal bone
support.
WILL YOU HELP
ME?
ROLE OF ORTHODONTIST
ORTHODONTIST
Role of orthodontist extends from infancy to
adulthood and during this long period of service, he
actively participate by :
Facilitating surgical repair of cleft lip and palate
by aligning cleft segments
Removing any interference to normal growth
Preparing cleft sites for grafting
Analyzing maxillomandibular growth
harmony/disharmony
Attempt to modulate growth
Integrating surgical and orthodontic treatment.
Providing good occlusion
Various procedures undertaken from
infancy to adulthood (in sequence)
Presurgical orthopedics
 Lip repair
 Alveolar molding
 Primary bone grafting
 Palatoplasty
 Expansion during primary dentition
During mixed dentition
Alignment of arches
Expansion and protraction of maxilla
Secondary bone grafting
During permanent dentition
Establishment of occlusion
Camouflage of skeletal discrepancy
Preparing patient for orthognathic surgery
In adulthood stage
Orthognathic surgery
Esthetic surgeries
Presurgical orthopedics
NAM (Naso -Alveolal molding)
Lip repair
Once the segments are
aligned with presurgical
orthopedics if used, lip are
ready to be repaired
surgically.
Timing of lip repair

Healthy infant can undergo
surgery anytime after birth.
It is preferable to wait at least until the end of the third month when labial
musculature has developed significantly to adequately support sutures
Moreover, immune system of child also develops significantly
These are the reasons for the universal acceptance of Millard's rule of
10.
According to Millard's rule of 10 –
infant should be at least
10 weeks old,
10 pounds weight
10 gm Hb
Gingivoperiosteoplasty (GPP)
The clefted alveolus is bridged
by gingival tissue and creates -
“a gingivoperiosteal tunnel
that facilitates bone healing
through guided tissue
regeneration (GTR) without
the need for bone grafting and
its associated donor site
morbidity”
Palatoplasty
Objectives of palatoplasty
The major objectives of a
cleft palate surgeries are :
1.To produce anatomic closure.
2 To produce normal speech.
3. To minimize maxillary growth
inhibition and dentoalveolar
deformities.
Timing of palatoplasty
Veau (1952) -suggested that the best time to close the palate (hard
and soft) is at the age of 18 months.
Malek (1983) -advises closure of the soft palate before the lip to
allow development of normal speech pattern (integrity of soft
palate is must for normal articulation).
Jean delaire (2000) -recommend simultaneous closure of the soft

palate and the lip.
But closure of the hard palate at this time leads to major
problems with growth in this area of great activity.
It is better to delay closure of the hard palate until the age of 18 months,
by which time defect become sufficiently narrow and can be closed with
only minimal displacement of the palatal maxillary fibromucosa. (less
scar tissue)
In the exceptional cases where cleft is too wide, it is better to postpone

closure to the end of the third year, by which time all the deciduous teeth
have erupted.
(erupted deciduous molars acts as guide and stabilizing factors by
articulating with mandibular teeth)
In more severe cases in which the maxilla fails to respond to palatoplasty
as expected, it is better to postpone palate closure till the age of 5 - 7
years.
(when it is possible to maintain the correct dimensions of the palatal
arch by a fixed orthodontic appliance).
Treatment in deciduous
dentition
Treatment in deciduous dentition
Possible causes for this cross bite are :

 The most obvious cause is hypoplastic maxillary segment
on the cleft side
Palatal scar tissue resulting from traumatic surgery
The canine adjoining the cleft will erupt palatally because of
the displacement of its developing tooth bud.
Timing of treatment-
Awaiting full eruption of the deciduous dentition before
initiating orthodontic treatment can be important because the
mandibular arch affords an excellent basis for determining
where to position the distorted maxillary parts and the
dentition.
In most of the cases, occlusal interference in canine

region leads to mandibular shift and gives impression of
buccal cross bite.
Contact between the palatally displaced
primary canine on the cleft side with the
mandibular canine causes a mandibular
shift and subsequent crossbite occlusion
(A-C).
Reduction of the cusps corrected the

occlusion.
If cross bite still persist, orthodontic expansion can be undertaken.
Because there is no bony union at midpalatal area, very light force

by any appliance (quad helix etc) can accomplish the job.
Orthodontic forces move the unfused bony maxillary segments

containing the erupted deciduous teeth as well as unerupted
permanent teeth.
This separation of unfused maxillary segments is absolutely

desirable in cleft patients. (Subtenly and Brodie 1954)
Retention after expansion
Some form of prolonged, adequate retention is imperative

because it may not be possible to stabilize the effects of
expansion against the adverse muscular forces and soft
tissue constrictive influences.
Treatment in mixed dentition
Treatment in mixed dentition
Primary goal of orthodontic treatment during mixed
dentition is to prepare cleft area for secondary bone graft.
But all the alignment tasks and cross bite corrections

should be achieved before graft placement
Invariably, there are rotations and displacements of teeth

especially near the cleft site.
Alveolar bone grafting (ABG)
ABG can provide stability to the maxillary arch thus
preventing future collapse of the alveolar segments
Provide adequate bone for the periodontal

Health and support of the teeth adjacent to the cleft
Improve nasal esthetics by normalizing the piriform rim

anatomy
Allow for closure of nasolabial fistulas, and improve

some speech parameters such as nasal air emission.
John O. Wirthlin The orthodontist′s role in the management of patients with cleft lip and palate undergoing alveolar bone
grafting Seminars in Orthodontics vol 23 , No 3, 2017: pp 255-260.
Unsuccessful alveolar bone grafting often leads
Tooth loss
Persistent nasal regurgitation
Persistent nasal air emission,
Can complicate and compromise future

orthodontic and orthognathic treatment.
The first successful alveolar bone graft -1914 by Drachter
Timing
Stellmach’s classification of grafting in

cleft patients
According to timing bone graft can be – Primary bone graft
- Secondary bone graft
- Tertiary bone graft

Primary alveolar bone grafting
Primary bone grafting is performed along with the primary repair
surgeries. (usually before the age of 18 months)
Goals of primary bone grafting
- Preserve & improve the arch form

- Stabilize a floating premaxilla in B/L CLP
- Achieve tooth eruption in the area of cleft
- Achieve functional & esthetic goals by closing the defect
Proponents claim the following advantages of primary bone
Prevention of maxillary collapse (Pickrell, Quinn, and Massengill

1968)
Improved bony support that enhances soft-tissue repair (Freide,

Johanson 1974)
Improved ability to eat and enhanced potential to develop normal

dentition. (Nylen, Körlof, Arnander, et al.1974)
Support for the alar base (Abyholm, Bergland, Semb 1980)

Significantly fewer anterior and posterior crossbites
(Helms, Speidel,and Denis 1987)
No facial growth attenuation -long term longitudinal

evaluation (Steinhauser1987)
No inhibition of facial growth or maxillary segment

collapse (Rosenstein,1991; Dado1993)
Opponents of primary bone grafting claim that :
The graft does not keep pace with vertical development of

the alveolar process (Jolleys, Robertson.1972)
Inhibits lateral and anterior growth of the maxilla.

(Rehrmann, Koberg, Coch H. 1970)
Restriction of maxillary growth in all three planes

(Hoberg, I970; Friede & Johnso, 1982)
Controversial, counterproductive with growth restriction
in long term (Wits enberg, 1987)
Poor outcomes are associated with primary bone grafting

(Shaw & Mars, 1992)
Retrusion of maxilla due to growth inhibition (Shafer,

1995)
Stal (1998) concluded that primary bone grafting has

fallen into disrepute because of limited experience &
variability of protocol
Jean delaire (2002) reviewed primary bone grafting
procedures and came to conclusion that the main factor
responsible for any ill effect produced by primary bone
grafting is surgical trauma (scar) to palatal tissue which
subsequently interfere with normal growth
The main factor which discourage primary grafting

procedure is insufficient amount of bone during eruption
of permanent dentition which invariably need another
secondary bone graft.
Among the various reasons for the continued use of primary alveolar
bone grafting are -
The reduction in the number of future surgical procedures
Possible improved periodontal support of the teeth adjacent to the

alveolar cleft
The ability to provide a bone graft to patients at the same time as

the lip repair if poor follow-up is anticipated and a bone graft
procedure would be unlikely at a later date.
Secondary Alveolar Bone Grafting
In 1972 Boyne and Sands first advocated secondary bone grafting
Goals of secondary bone grafting
Closure of vestibular and palatal oral nasal fistulae .
Providing sufficient quantity and appropriate quality of bone

to allow eruption of the permanent lateral incisor and canine
teeth
Provision of support for the lateral ala of the nose.
Provision of suitable bony architecture of the premaxilla
Provision of adequate bone stock for ultimate placement

of osseointegrated implant
Secondary bone grafting
According to timing
Early secondary
bone grafting
Secondary bone Intermediate

grafting secondary bone
grafting
Late secondary
bone grafting
Intermediate alveolar bone grafts between the age of 6-9
The exact timing should be patient specific
The development of the dentition that drives the decision

and not Chronological age.
The goal should be to perform the graft early enough to

allow the erupting permanent dentition to have good
alveolar support, but wait as long as possible to limit the
possible negative side effects on the growth of the maxilla.
The success of alveolar bone grafting is increased if it
Is performed prior to the eruption of the maxillary canine
on the clefted side
Intermediate secondary alveolar bone grafting when the
unerupted canine has 1/2 to 2/3rds of its root developed.
Tooth must erupt through the graft material because the

erupting tooth will stimulates growth of graft bone, thereby
will maintain vitality of graft material.
The root development of the unerupted lateral incisor

should be Used as a gauge to determine the timing of the
alveolar bone graft and not the canine.
When comparing intermediate to early secondary bone grafting there are two
more importance variables to take into consideration
The first is the eruption

path of the Central incisor.
The ability to comply

with pre graft
orthodontics.
Pre-graft Orthodontics
Quadhelix to expand prior to ABG
Various Types Of Expansion Devices Used In Trearment Of CLP Patients
Protraction face mask
FACE MASK THERAPY

Used in mild maxillary deficient
cleft patient.
Orthopedic forces for maxillary
protraction -
350-500 gm
/side
10-12 hr/day
12-15 months.
Atypical bracket placement
Schematic drawing of the bone grafting procedure
2.
1.
3. 4.
Jan Lilja Alveolar bone grafting Jan Indian J Plast Surg Supplement 1 2009 Vol 42 pp s110-s115
Post Operative Splints
The proposed benefits of these splints include-
Retention of the pre graft arch form

change
Protection of the surgical site,
Stabilization of the premaxilla in the

case of bone grafts in patients
With complete bilateral alveolar
clefts.
Evaluation of Results
THE BERGLAND SCALE 1986

Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent
orthodontic treatment. Cleft Palate J. 1986;23:175–205.
KINDELAN SCALE 1997
Kindelan JD, Nashed RR, Bromige MR. Radiographic assessment of secondary autogenous alveolar bone
grafting in cleft lip and palate patients. Cleft Palate Craniofac J. 1997;34:195–198.
THE CHELSEA SCALE- H. WITHEROW et al 2002
Alveolar bone graft scale (stage 1, 8-point scale).
H. Witherow, s. Cox, e. Jones, r. Carr, n. Waterhouse, A New Scale to Assess Radiographic Success of
Secondary Alveolar Bone Grafts Cleft Palate–Craniofacial Journal, May 2002, Vol. 39 No. 3
1 1
The Chelsea scale- H. WITHEROW et al
The Chelsea scale- H. WITHEROW et al
SWAG SCALE (The Standardized Way to Assess Grafts)
Kathleen Russell, Ross E. Long& et al Reliability of the SWAG—The Standardized Way to Assess Grafts Method for
Alveolar Bone Grafting in Patients With Cleft Lip and Palate Cleft Palate–Craniofacial Journal,Month 0000, Vol. 00 No. 00
Treatment in Permanent dentition
A bone graft, if indicated, would have been placed.
The lateral incisor and canine on the cleft side would

have erupted through the bone graft in the line of the
cleft.
Potential maxillomandibular disproportions would have

been identified.
Objectives of treatment in Permanent dentition are :
To provide good occlusion
To monitor and if feasible, correction of any skeletal base

discrepancy
To provide good long term retention
Preparing patient for surgery, if needed

Occlusion considerations
Once all the teeth are erupted, precise space planning can be done.
Minor space discrepancies can be resolved without extraction by carefully

advancing the incisors which will improve patient’s profile also
First advancing the incisors root tips labially followed by crown movement
frequently make it possible to achieve sufficient arch length.
Incisor labial root torque and incisor advancement can promote observable
development of bone in the anterior maxillary region.
(Delaire 1971, Verdon and salognoc 1977)
Extractions should be avoided in the maxillary arch
because it can further increase the undesirable retruded
relationship of the maxillary complex.
Extractions, although undesirable in the upper arch, may be

necessary because the bony segments may not be adequate
to accommodate all of the maxillary teeth.
DISTRACTION OSTEOGENESIS
The technique was popularized by Ilizarov in the 1940s to

lengthen long bones without the need for a graft
McCarthy et al in1992, was the first to report a craniofacial

application in patients with congenital deformities of the
mandible
The goal of DO is to create new bone across an osteotomy site
by gradually moving the two sides of the bone apart.
Hitesh Kapadia Management of severe maxillary hyopolasia with distraction osteogenesis in patients with cleft lip and
palate Seminars in orthodontics, vol 23 , No 3, 2017: pp 314-317
There are three distinct phases in distraction:
The latency or lag Phase - initial bone formation occurs at the gap
between the bones.
The activation phase.- Using the distraction

Appliance, the bone segments are gradually pulled apart
The consolidation phase - Once the planned position of the

bone is reached, the newly formed regenerate is allowed to
mineralize
The benefits of distraction osteogenesis in a growing patient
with cleft lip and palate
Generation of new bone at the site of osteotomy
Large skeletal movement without the need for a bone graft
Gradual stretching of the surrounding soft tissues.
The increased magnitude of maxillary advancement with greater stability

can be attributed to the slow and incremental movement of the maxilla
coupled with maintaining maxillary position with the use of the
distraction appliance during consolidation.
Various types distracters used in mid
facial deformity
Internal Distracter
Humam Saltajia; et aiLong-term skeletal stability after maxillary advancement with distraction osteogenesis in cleft lip and
palate patientsA systematic review Angle Orthodontist, Vol 82, No 6, 2012 Pp1115-1122
External distracter
Humam Saltajia; et aiLong-term skeletal stability after maxillary advancement with distraction osteogenesis in cleft lip and
palate patientsA systematic review Angle Orthodontist, Vol 82, No 6, 2012 Pp1115-1122
Pre- surgical orthodontics-
All dental compensations present in a class III skeletal malocclusion
are removed
The teeth aligned in an optimal position relative to the skeletal base

and alveolar process.
Coordinate maxillary and mandibular arch widths,
Compatibility of occlusal planes
Appropriate intercuspation.
Procedure
Le Fort I osteotomy+the distraction

appliance
The patient enters a latency period of four to

six days
The distraction appliance is

Then activated at a rate of 1mm per day
Lateral cephalograms at the Appropriate interval to
ensure the appropriate vector for the intended
movement was selected
Interach elastics to guide the Maxilla to the optimal

occlusion determined in the pre-surgical plan.
Once Complete with advancement, the distractor

remains in place for six to eight weeks or Longer during
the consolidation phase.
Consideration of skeletal base discrepancy
No skeletal
discrepancy
Skeletal base
discrepancy Mild
Moderate to
severe
Laura Mancini, Travis L. Gibson, Barry H. Grayson, Pradip R. Shetye Orthodontic Treatment in Adolescents with
Cleft Lip and Palate ; Seminars in orthodontics, vol 23 , No 3, 2017: pp 295-304
No skeletal base discrepancy-
 Class I skeletal relationship
 MP Angle- within normal limits
 Adequate buccal dental overjet in posterior region
 Class II skeletal relationship.
 Profile- straigt/convex
Well-balanced.
Mild skeletal base discrepancy
Mild class III skeletal relationship

Slightly high MP angle.
2-3mm of skeletal transverse discrepancy
Profile– straight
Lower ant. Facial height –slightly long
Everted lower lip
Orthodontic t/t objectives for patients with mild skeletal discrepancy
 “Dental camouflage”
 Skeletal discrepancy is managed with skeletal
anchorage
 Class III interarch elastics -to achieve
acceptable results
 Non exraction or extraction ( class III exraction
pattern)
 Transverse discrepancy –TPA
SME (1-2 turn
/week)
 RME –may re open existing palatal fistula
Moderate to severe skeletal discrepancy
Significant Class III skeletal discrepancy

-ve anterior overjet
Complete posterior crossbite-unilateral/bilateral
Profile –concave
Depressed infra orbital and malar skeletal anatomy on cleft side
Increased lower anterior facial height
Incomoetant lips /lip strain
Orthodontic t/t objectives for patients with
moderate to severe skeletal discrepancy
In these instances, it becomes important to again

undertake maxillary protraction to improve the facial
profile and facial appearance. (Simonsen 1981,
Galletto 1988)
However, Subtenly (1980) claimed that during later

stage of growth, face mask do little enhancement of
skeletal maxillary development and changes are
seemed to be restricted to maxillary dental arch
advancement.
Late maxillary protraction.
LeFort 1 osteotomy, Bollard plates and mandibular TADs and maxillary protraction
techniques to distract the maxilla forward.
Stephen L.-K. Yen Late maxillary protraction techniques for cleft lip and palate Seminars in orthodontics, vol
23 , No 3, 2017: pp 305-313
Late maxillary protraction.
LeFort 1 osteotomy, Bollard plates and mandibular TADs and maxillary protraction
techniques to distract the maxilla forward.
23 , No 3, 2017: pp 305-313
Post treatment results
23 , No 3, 2017: pp 305-313
The use of TAD-supported bonded RPE, LeFort 1 osteotomy
and maxillary protraction
23 , No 3, 2017: pp 305-313
The use of TAD-supported bonded RPE, LeFort 1 osteotomy and maxillary
protraction
23 , No 3, 2017: pp 305-313
Non-surgical maxillary protraction combined with initial
sutural loosening.
23 , No 3, 2017: pp 305-313
Non-surgical maxillary protraction combined with initial sutural loosening.
23 , No 3, 2017: pp 305-313
When the proper maxillomandibular relationship is not
obtained in cleft patients with conventional
orthodontic/orthopedic methods, orthognathic surgery is
indicated.
In the past, it was common for the mandible to
be set back to produce a normal occlusion with
the retropositioned maxilla (this was mainly
because of fear of devitalizing maxilla from the
surgery), but this produced a flat, unaesthetic
facial appearance.
Currently, the standard treatment is a Le Fort I
maxillary advancement.
If the patient has a small chin or if an extensive

setback of the mandible is required, an
advancement genioplasty can be performed
during the same time . If the chin is excessively
long, it can be reduced in vertical height at the
same time (Munro, Salyer, 1990)
Lefort I
Lefort I and mandibular setback
(discrepancy more than 10 mm)
POST SURGICAL ORTHODONTICS
•Shortly after surgery, when patient is able to tolerate post surgical
records, cephalograms are performed to determine whether surgical
treatment plan is achieved
•Intermaxillary elastics may be used to facilitate mandibular dentition

into splint bite
•After midface surgery, patient have difficulty in breathing through

nose due to edema and swelling
•Oral functional physical therapy is often necessary after orthognathic

surgery, temporomandibular joint ankylosis release and mandibular
distraction to re-establish normal range of motion and masticatory
function
Management of missing teeth
Most common tooth – maxillary lateral incisor on cleft side(50-90%)
A supernumerary tooth in the cleft region is the second most common

anomaly.
Agenesis of ipsilateral premolars & other anterior teeth

Canine substitution
Is a favorable option when maxillary canine erupt in the more mesially

oriented position just distal to maxillary central incisor
If only one or both maxillary lateral incisors are missing –close the
space and substitute the lat. Incisor with canine.
First premolar is advanced and substituted for canine

Canine substitution is most esthetic when bracket position is modified
to improve the appearance of gingival height relative to the central
incisor
Enameloplasty, composite build ups or veneers, combination with

gingivectomy of the bicuspid to maximize esthetics with the
contralateral side
Prosthetic Replacement
A second option for the

missing lateral incisor/s, is
to maintain the space for
future prosthetic
replacement, such as an
implant, a bridge or a pontic
on a removable appliance
Primary Tooth Retention without Permanent Successors
Maintain the primary tooth for as long as possible to maintain the

alveolar bone level.
If extraction of the primary tooth is required, every effort should be

made to maintain as much bone as possible and to preserve the buccal
cortical plate around the site of the cleft defect.
Alternatively, the tooth may be extruded orthodontically to bring the

bone level further occlusally prior to extraction.
Velopharyngeal Mechanism
The Velopharyngeal Mechanism consists of a

muscular valve that extends from the posterior
surface of the hard palate (roof of mouth) to the
posterior pharyngeal wall. The mechanism
includes the velum (soft palate), lateral pharyngeal
walls and the posterior pharyngeal wall
Jamie L. Perry, Anatomy and Physiology of theVelopharyngeal Mechanism Seminars in speech and
language/volume 32, number 2 2011 Pp 83-92
The function of the Velopharyngeal Mechanism is to
create a tight seal between velum and pharyngeal walls
to separate the nasal and oral cavities
Jamie L. Perry, Anatomy and Physiology of theVelopharyngeal Mechanism Seminars in speech and
language/volume 32, number 2 2011 Pp 83-92
VPD is of 3 types:
A) Velopharyngeal Mislearning:- due to articulation
difficulties
B) Velopharyngeal Incompetence:- due to functional
abnormalities( paresis , dysarthia)
C) Velopharyngeal Insufficiency:- structural problems like
cleft , bifid uvula etc
VELOPHARYNGEAL
INSUFFICIENCY
Velopharyngeal insufficiency
is a disorder resulting in the
improper closing of the
velopharyngeal spincture
(soft palate muscles in the
mouth) during speech
allowing the air to escape
through nose instead of the
mouth
The main speech symptoms of Velopharyngeal Insufficiency
are-
1. Hyper nasality
2. Nasal air emission
3. Misarticulation of certain words
Treatment of VPI
SPEECH THERAPY-
Treatment focuses on teaching the
child the correct manner and place of
articulation
NON SURGICAL
MANAGEMENT
Pharyngeal Obturator
RECENT ADVANCES
•Fetal surgery – done in intrauterine

life ( prior to 29 weeks)
•Non life threatening defects like cleft
lip , cleft palate, pierre robin
syndrome, Treacher –Collins FETENDO
syndrome, craniofacial microsomia
•Open fetal surgery
•FETENDO- (Fetal endoscopic
surgery)
•FIGS-( Fetal image guided surgery)
FIGS
ADVANTAGES
•Provide a scarless repair, “ripple
effect” is eliminated
•Correct the primary deformity
•Prevent secondary deformity
•Give the parents a normal
appearing child at birth
Conclusion
Providing care for children born
with cleft lip and palate is a
complex , challenging, and
ultimately rewarding requiring
the input of an extensive team of
dedicated health care
professionals . We a as an
Orthodontist are fortunate to get
an opportunity to serve as a key
member for this social cause.
References
•Travis L.Gibson, Pradip R.Shetye - Collaborative care and the modern
craniofacial treatment team ; Seminars in orthodontics, vol 23 , No 3, 2017: pp
255-260.
•Katherine W. L. Viga and Ana M. Mercadob Overview of orthodontic care for
children with cleft lip and palate, 1915-2015 Am J Orthod Dentofacial Orthop
2015;148:543-56)
•Gandedkar NH, Koo CS, Chng CK, Por YC, Yeow VK, Sng KW. Role of the
“craniofacial orthodontist” in a “craniofacial team”. J Indian Orthod Soc
2018;52:S4-13.
•John O. Wirthlin The orthodontist′s role in the management of patients with cleft
lip and palate undergoing alveolar bone grafting Seminars in Orthodontics vol
23 , No 3, 2017: pp 255-260.
•Jan Lilja Alveolar bone grafting Jan Indian J Plast Surg Supplement 1
2009 Vol 42 pp s110-s115
•Letizia Perillo, Maddalena Vitale,a Fabrizia ’Apuzzo, Gaetano Isola,
Riccardo Nucera,and Giovanni Matareseb Interdisciplinary approach for
a patient with unilateral cleft lip and palate Am J Orthod Dentofacial
Orthop 2018;153:883-94
•Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar
cleft by secondary bone grafting and subsequent orthodontic treatment.
Cleft Palate J. 1986;23:175–205.
•Kindelan JD, Nashed RR, Bromige MR. Radiographic assessment of
secondary autogenous alveolar bone grafting in cleft lip and palate
patients. Cleft Palate Craniofac J. 1997;34:195–198.
•H. Witherow, s. Cox, e. Jones, r. Carr, n. Waterhouse, A New Scale to Assess
Radiographic Success of Secondary Alveolar Bone Grafts Cleft Palate–Craniofacial
Journal, May 2002, Vol. 39 No. 3
•Laura Mancini, Travis L. Gibson, Barry H. Grayson, Pradip R. Shetye Orthodontic
Treatment in Adolescents with Cleft Lip and Palate ; Seminars in orthodontics, vol
23 , No 3, 2017: pp 295-304
•Kathleen Russell, Ross E. Long& et al Reliability of the SWAG—The Standardized
Way to Assess Grafts Method for Alveolar Bone Grafting in Patients With Cleft Lip
and Palate Cleft Palate–Craniofacial Journal,Month 0000, Vol. 00 No. 00
•Hitesh Kapadia Management of severe maxillary hyopolasia with distraction
osteogenesis in patients with cleft lip and palate Seminars in orthodontics, vol 23 ,
No 3, 2017: pp 314-317
•Stephen L.-K. Yen Late maxillary protraction techniques for cleft lip and
•Jamie L. Perry, Anatomy and Physiology of theVelopharyngeal
Mechanism Seminars in speech and language/volume 32, number 2 2011
Pp 83-92
•Humam Saltajia; Michael P. Majorb; Mostafa Altalibib; Mohamed
Youssefc; Carlos Flores-Mird Long-term skeletal stability after maxillary
advancement with distraction osteogenesis in cleft lip and palate
patientsA systematic review Angle Orthodontist, Vol 82, No 6, 2012
Pp1115-1122

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Dept. of Orthodontics & Dentofacial Orthopedics , V.Y W. S.

THE ROLE OF ORTHODONTIST IN

Guided by- Presented By-

a furrow in the palatal

a breach in the continuity

International Journal of Orthodontia

International Journal of Orthodontia and Oral Surgery

International Journal of Orthodontia and Dentistry for Children

American Journal of Orthodontics and Oral Surgery

American Journal of Orthodontics (AJO)

American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO)

 By 1943, the American Cleft Palate Association (ACPA) was

1964 January - The Cleft Palate Journal, launched , is the official

currently published as the Cleft Palate- Craniofacial Journal.

1. An emotional disturbance and

1. Close vestibular and palatal oronasal fistula

Timing of lip repair

Moreover, immune system of child also develops significantly

Jean delaire (2000) -recommend simultaneous closure of the soft

In the exceptional cases where cleft is too wide, it is better to postpone

Possible causes for this cross bite are :

In most of the cases, occlusal interference in canine

Reduction of the cusps corrected the

Because there is no bony union at midpalatal area, very light force

Orthodontic forces move the unfused bony maxillary segments

This separation of unfused maxillary segments is absolutely

Some form of prolonged, adequate retention is imperative

But all the alignment tasks and cross bite corrections

Invariably, there are rotations and displacements of teeth

Provide adequate bone for the periodontal

Improve nasal esthetics by normalizing the piriform rim

Allow for closure of nasolabial fistulas, and improve

Persistent nasal regurgitation

Persistent nasal air emission,

Can complicate and compromise future

Stellmach’s classification of grafting in

- Secondary bone graft

- Tertiary bone graft

Goals of primary bone grafting

- Preserve & improve the arch form

Prevention of maxillary collapse (Pickrell, Quinn, and Massengill

Improved bony support that enhances soft-tissue repair (Freide,

Improved ability to eat and enhanced potential to develop normal

Support for the alar base (Abyholm, Bergland, Semb 1980)

No facial growth attenuation -long term longitudinal

No inhibition of facial growth or maxillary segment

The graft does not keep pace with vertical development of

Inhibits lateral and anterior growth of the maxilla.

Restriction of maxillary growth in all three planes

Poor outcomes are associated with primary bone grafting

Retrusion of maxilla due to growth inhibition (Shafer,

Stal (1998) concluded that primary bone grafting has

The main factor which discourage primary grafting

The reduction in the number of future surgical procedures

Possible improved periodontal support of the teeth adjacent to the

The ability to provide a bone graft to patients at the same time as

Goals of secondary bone grafting

Closure of vestibular and palatal oral nasal fistulae .

Providing sufficient quantity and appropriate quality of bone

Provision of suitable bony architecture of the premaxilla

Provision of adequate bone stock for ultimate placement

Secondary bone Intermediate

The exact timing should be patient specific