Overview: Treatment/Facial Growth
Overview of Treatment
From birth to late adolescence, a typical child with a cleft of the lip and palate (image 1) undergoes a number of treatments. Ideally, these are coordinated by a cleft palate/craniofacial team serving that area (image 2). It is important for dentists who interact with the patient’s family to understand the treatments and their sequencing—especially since you are very likely to be asked about what is happening and whether it sounds right to you. As an overview (image 3):
- In infancy, to prepare for lip repair, a dental specialist may do presurgical orthopedics to align the maxillary cleft segments. The surgeon repairs the lip and cleft palate and may place an early alveolar bone graft. The social worker counsels parents on future care. The geneticist tests for syndromes in the child and the risk of the parents to have another child with a cleft. The speech pathologist monitors speech development. The audiologist/ENT surgeon monitors middle ear function, because children with a cleft palate may need tubes in the middle ear for fluid drainage.
- During the preadolescent or mixed dentition stage, between the ages of 5 and 8 years old, the patient will have a bone graft placed in the alveolus—alveolar bone grafting. In conjunction with this, there will be an initial phase of orthodontics to align the dentition and expand the maxillary arch.
- Later during adolescence, there will be a second phase of orthodontics, and after the adolescent growth spurt is completed, the patient may need orthognathic surgery. Also, decisions will be made to orthodontically close spaces for missing teeth or maintain space so missing teeth can be prosthetically replaced. Finally, residual soft tissue deficiencies and asymmetries of the lip and nasal regions may need to be surgically revised by the plastic surgeon for improved esthetics.
 Image 1, cleft patient: Fourteen-year-old girl with typical sequelae of a treated cleft lip and palate. |  Image 2, cleft team: Meeting of the UNC Cleft Craniofacial Center Team. Members are seen discussing patients’ treatment plans. |
 Image 3, cleft team duties: Cleft treatment: who does what, when. |
Overview: Facial Growth and Treatment
All the surgical procedures have the potential to adversely affect the patient’s facial growth—some more so than others. Data in support of this finding comes from adult patients who reside in countries where there is little or no medical treatment and who have not had surgical repairs. These patients have normal midfacial depth and height with obvious dentoalveolar adaptations in the cleft site (image 1).
Repair of an isolated cleft lip usually has little or no effect on facial growth, but repair of a palatal cleft often does. During the palate repair, soft tissue mucoperiosteal flaps are lifted from the cleft halves of the hard palate and are brought together in the midline to close the palatal defect. Scar tissue forms as the tissue heals. This scarring restricts growth of the maxilla (image 2). Modern surgical techniques do not create as much scar tissue as older methods, and the need for orthognathic surgery in adolescence for cleft patients because of maxillary deficiency is decreasing.
Another factor that influences whether a cleft patient will need orthognathic surgery is the patient’s inherited facial profile. In the cleft population as in the general population, individuals have inherited facial profiles that are Class I, Class II, or Class III (image 3). Those with Class II profiles are more able to mask the developing midfacial deficiency, while in those with Class I or Class III profiles, midfacial deficiency will be more apparent. Thus, the patient’s inherent growth pattern may either mask or enhance the midfacial deficiency.
In general, the more severe the cleft of the palate, the worse the midfacial deficiency after it is repaired, but the quality of the initial surgery is the major determining factor. Image 4 provides a summary of these factors.
 Image 1, adult with unrepaired cleft: Note the normal facial proportions in this Sri Lankan adult with an unrepaired cleft lip and palate. There are dentoalveolar adaptations in the cleft site, but normal jaw growth occurred. |  Image 2, adult with repaired cleft: Deficiency of the midface, as seen in these two patients—the one on the right is more severe—often occurs once the palate is repaired because scarring limits growth. |
 Image 3, cleft patients, skeletal Class II/III: Patients with Class II profiles are able to mask the midfacial deficiency. On the left, the Class II is due mainly to a retrognathic mandible, and on the right, a prognathic maxilla. |  Image 4, overview: Overview of growth effects of palate surgery. |
Infancy/Primary Dentition
Sequence of Cleft Treatment
An important early step in treatment is the surgical repair of the cleft lip. It is performed within the first 12 weeks of life by the plastic surgeon; to facilitate the surgery, either presurgical infant orthopedics or a lip adhesion may be recommended (image 1). Once the displaced cleft segments (image 2) are repositioned, the surgeon can repair the lip under less tension.
Infant Orthopedics
- For the baby with a unilateral cleft lip and palate, an orthopedic appliance is used to mold and approximate the maxillary cleft segments decreasing the facial asymmetry.
- For the baby with a bilateral cleft lip and palate, a similar appliance is used to expand the maxillary segments and to retract and approximate the premaxillary segment to a more normal position (image 3).
In the 1965-80 era, infant orthopedics was very popular; however, today the treatment is considered less useful than originally thought. Many centers have discontinued the practice. Those still in favor of it cite an improved lip and nasal esthetics, which appears to be true in the short term but is questionable in the long term. There are many different types of appliances. Some are removable and others are fixed to the maxilla with pins (image 4). Newer appliances are designed to mold the nasal cartilage as well as the maxillary segments.
Lip Adhesion
An alternative to molding appliances is a lip adhesion. This is a surgical procedure to repair the superficial skin tissues of the lip (image 5). This limited lip repair molds the maxillary segments, and once the segments are approximated, the surgeon then completes the definitive full-thickness repair of the lip muscles.
 Image 1, overview: Overview of treatment steps in infancy. |  Image 2, bilateral cleft infant pre-tx: Collapsed maxillary segments in a baby with a bilateral cleft lip and palate. |
 Image 3, infant with molding appliance: Orthopedic molding appliance in place to expand the maxillary segments. |  Image 4, effect of appliance: Top: Maxillary segments fully expanded. Note the appliance is fixed to the maxilla with pins. Bottom: Premaxilla in position after expansion created room for it. |
 Image 5, lip adhesion: Lip adhesion. Superficial tissues of the lip—skin and mucosa—are sutured together to mold the segments prior to the definitive lip repair. |
Sequence of Cleft Treatment, cont’d.
At some centers, a bone graft may be placed in the alveolus around the same time as the lip repair. This bony defect in the alveolar process requires a graft, and an important question is when the alveolus should be grafted. There are three possibilities:
- Now, very early as an infant (images 1, 2);
- Late—too late—after the permanent dentition has erupted; and
- In the mixed dentition before the eruption of the permanent teeth near the cleft site.
Very early grafting in infancy now is rarely used because studies have demonstrated that the practice is detrimental to midfacial growth. Late grafts are very difficult to accomplish successfully. Mixed dentition grafts now are standard practice.
Another treatment that is sometimes considered during infancy is the use of a feeding appliance, which consists of a full-coverage palatal acrylic plate that occludes the palatal cleft. The thought is that occluding the cleft palate will improve swallowing and hence allow the baby to feed more effectively. As the baby grows, these plates must be remade to fit the palate. They are discontinued once the palate is repaired at around one year of age. Except in special circumstances, however, these appliances are not recommended because their effectiveness for this purpose has not been demonstrated. The nutritionist or nurse practitioner affiliated with the team can advise the parents on the use of special nipples and other techniques to maximize bottle feeding without the use of a feeding appliance.
 Image 1, Harvesting bone graft: Rib graft harvested from the chest cavity of this baby. |  Image 2, Primary bone graft: Rib bone being placed in the alveolus of this baby. |
Sequence of Cleft Treatment, cont’d.
The cleft of the palate is repaired between one to two years of age (image 1). The exact timing is controversial because the speech pathologist would prefer that the repair occurs early (before one year of age) so that an intact palate is present as speech development occurs. Conversely, the surgeon and orthodontist would prefer to wait until there is sufficient development and maturation of the hard and soft tissues to facilitate the surgical repair and decrease the chance of impaired growth of the maxilla. In most centers,the timing of the surgery has become earlier as surgical techniques have improved and the chance of growth problems has decreased. At present, the palate usually is repaired around one year of age.
The surgery involves lifting soft tissue flaps from the cleft halves of the palate and suturing the flaps in the midline to close the bony defect (image 2). Thus, the defect is closed with soft tissue only—no bone is placed in the midpalatal defect. There are many designs of flaps for lip and palate closure. For further information, see Facial Clefts and Craniosynostosis: Principals and Management (Eds: TA Turvey, KWL Vig, RJ Fonseca. WB Saunders Co., 1996).
At age 3-5 years, there may be the temptation to start orthodontic treatment to expand the maxillary arch. Generally, orthodontics at this age has little long-term effect and for that reason can be considered a waste of time and effort. It is better to wait until the mixed dentition, when the permanent incisors and first molars have erupted.
During the preschool years, the child will attend regular team evaluations and may have other treatments, such as general dental care and surgeries to improve soft palate function, middle ear function (the insertion of ear tubes), and lip function and esthetics.
 Image 1, schematic of palate repair: Diagrammatic view of palate closure. Soft tissue flaps are lifted from the palatal halves and sutured in the midline. Note a cleft still remains in the bone of the alveolus. |  Image 2, steps in palate repair: A. Outline of incisions are drawn on the tissues (broken line). B. Incisions are made and palatal tissues undermined to release the palatal muscles. C. Muscles are sutured in the midline. D. Overlying skin is sutured to complete the operation. |
 Image 3, overview: Overview of treatment age 1-5. |
Preadolescent/Mixed Dentition
Alveolar Graft
At around 6 to 8 years of age, if an early alveolar bone graft (as an infant) was not placed—and most likely it would not have been—then the child is assessed for the proper time to place an alveolar bone graft (image 1). Grafting in the mixed dentition is the most common practice. Support for this practice comes from studies that show minimal effects on midfacial growth from alveolar graft surgery at this age. This is because much of the growth of the maxilla (especially in width) has already occurred, so the surgery has little negative impact.
In the mixed dentition, just about every child with a cleft has malaligned maxillary incisors, and often there is collapse of the posterior segments (image 2). The graft is timed either for the eruption of the permanent lateral incisor near the cleft site—grafting closer to 6 to 7 years of age—or the permanent canine—grafting closer to 7 to 8 years of age. In most cases, the lateral incisor near the cleft is missing, so it is more common to graft for the canine around 7 to 8 years (image 2). The graft must be placed before the specific tooth has erupted through the bone.
Alveolar bone grafting at this time is generally done in conjunction with a first phase of orthodontic treatment. There are two reasons for the phase I treatment:
- to bring the incisors into position (often they are rotated when they erupt, due to stretching of the tissues during palate repair),
- and, more important,, to prepare the maxillary arch for the alveolar bone graft.
 Image 1, overview |  Image 2, cleft grafting: If a permanent tooth erupts through the area of an alveolar cleft after a graft has been placed, it brings bone with it, and the cleft is obliterated. |
Tina S., Age 7 1/2
Consider Tina, a 7 1/2-year-old girl with a left unilateral cleft of the lip and palate that was repaired in infancy. In the full face view (image 1), you can see the lip scar and the difference in shape of the nostril between the affected and normal sides. For Tina, both the lip and nose are not major problems. Revision of the lip and/or nostril are major reasons for additional plastic surgery in children with clefts.
In the profile view (image 2), you can see that she has a straight profile, with full lips and less prominence of the midface than is normal for a child of this age. The cephalometric radiograph (image 3) and tracing (image 4) confirm moderate midface deficiency due to restricted maxillary growth, which is almost surely the result of scarring after the palate repair.
A periapical radiograph of the cleft area (image 5) shows that the cleft of the alveolus extends through the area where the lateral incisors should be. Both maxillary lateral incisors are missing.
 Image 1, full face view: Tina, age 7 1/2, after cleft surgery in infancy. |  Image 2, profile view: Tina, age 7 1/2, after cleft surgery in infancy. |
 Image 3, lateral ceph: Tina, age 7 1/2, after cleft surgery in infancy. |  Image 4, ceph tracing: Cephalometric tracing: moderate maxillary deficiency. |
 Image 5, radiograph, cleft area: Periapical view of the incisor near the cleft site, showing a thin layer of bone lining the root and separating it from the cleft site. The lateral incisors are missing bilaterally. |
Tina S., Age 7 1/2
Intraorally, on the cleft side, the permanent central incisor has erupted rotated nearly 90 degrees (images 1, 2). This often occurs, presumably because of stretching of tissues during repair of the palatal cleft. The cleft through the alveolar process, closed only by soft tissue and extending up into the base of the nose, can be seen clearly. Note that the maxillary dental arch is somewhat V-shaped, because the posterior segment on the cleft side is rotated toward the midline as it approaches the alveolar cleft (image 2).
The dental occlusion on the noncleft side is essentially normal (image 3), but there is a posterior crossbite tendency on the cleft side, more pronounced in the canine region (image 4). This also is related to scar tissue that restricts transverse growth of the repaired palate.
The panoramic radiograph shows that root formation of the permanent canine on the cleft side has begun, with about 1/3 of the root already completed—so eruptive movement of this tooth has started (image 5). Eruption does not occur until root formation begins.
 Image 1, frontal: Severe rotation of the incisors on the cleft side often is noted when these teeth begin to erupt. |  Image 2, maxillary occlusal: Note the inward rotation of the posterior segment of the dental arch on the cleft side. |
 Image 3, right lateral: Occlusion is normal on the noncleft side. |  Image 4, left lateral: Posterior crossbite on the cleft side, more in the canine than the molar region. |
 Image 5, panoramic radiograph: Note the cleft through the alveolar process and the beginning of root development of the permanent canine on the cleft side. |
Tina S., Problems/Plan
Tina’s problems are summarized in image 1. At this point, alignment of the rotated central incisors and expansion in the canine region are needed, but the key factor is placement of a bone graft to the cleft area of the alveolar process. This must be timed so that the maxillary canine will erupt through it. For Tina, because of the root development of the canine—over 1/3 of the root of the canine was developed—there was not enough time for pregraft orthodontic alignment, and the graft was placed at age 7 years, 11 months. The surgical steps involved in alveolar grafting are shown in image 2.
The bone for the graft can be harvested from either the patient’s hip or cranium, after which it is ground into bone chips. Once the site has been surgically prepared, the bone chips are packed into the area. The postgraft panoramic radiograph shows the material packed into the cleft, with the canine poised to erupt through this area (image 3).
The purpose of any bone graft is to stimulate its own replacement with new bone. As the canine erupts through the grafted area, it brings bone with it so that the graft site is completely remodeled. This creates an intact maxillary arch much more successfully than trying to graft an alveolar defect after the teeth have erupted and also provides sound periodontal support for the erupted canine. Delaying the graft until after the canine has erupted will result in poor periodontal support for the canine. The bone graft also serves to elevate the base of the nose, improving the esthetics of the nasolabial area (images 4, 5).
 Image 1, problem list/plan |  Image 2, steps in alveolar graft: A. Outline of incisions are drawn on the tissues (broken line). B. Flaps are reflected buccally and palatally through the cleft and the nasal mucosa is sutured together to form a base for the bone graft. C. Bone chips are placed in the cleft site and a buccal flap is lifted, the tissues undermined, and the flap is used to close the alveolar cleft. D. The buccal and palatal tissues are sutured to complete the operation. |
 Image 3, postgraft pan: Postgraft panoramic radiograph. The canine now is beginning to erupt toward the grafted area. |  Image 4, facial change: Facial appearance pre- and postgraft. The improved contour of the nostril on the cleft side is due to better support of its base. |
 Image 5, profile change: Profile appearance before/after graft: minimal change. |
Tina S., Treatment Sequence
Following the placement of the graft, at age 8 1/2, phase 1 orthodontic treatment was started for Tina, with the goal of correcting the severe rotation of the maxillary right central incisor and bringing the central incisors to the midline. Initially, a flexible rectangular wire (NiTi) attached to the central incisors and molars was used (images 1-4).
Incisor alignment may occur either before or after the grafting. During incisor alignment prior to grafting, care must be exercised to avoid uprighting the root of the permanent incisor near the cleft so that it contacts the bony lining of the cleft. This would induce root resorption. Excessive orthodontic force will move the root into the cleft where there is no bone—an even worse situation. If there is any doubt, the incisors should be aligned after grafting to minimize iatrogenic damage to the root of the incisor near the cleft. In general, postgraft orthodontic treatment can be started soon after the graft has been placed and as long as the patient is comfortable enough to tolerate it.
 Image 1, frontal view: Tina, age 8 1/2 yrs, phase 1 orthodontic treatment. |  Image 2, maxillary occlusal: Tina, age 8 1/2 yrs, phase 1 orthodontic treatment. |
 Image 3, right lateral: Tina, age 8 1/2 yrs, phase 1 orthodontic treatment. |  Image 4, left lateral: Tina, age 8 1/2 yrs, phase 1 orthodontic treatment. |
Tina S., Treatment Sequence
At age 9 years, 9 months, the permanent canine was erupting through the graft site, and the cleft already was obliterated (image 1). With the position of the central incisors corrected, the brackets on the central incisors were removed (images 2-3) and the molar bands were left in place to help stabilize the removable retainer needed to control the position of the incisors (image 3). Soon afterward, the maxillary primary canines were extracted to relieve crowding and allow the permanent canines to erupt mesially, so that they would replace the missing lateral incisors. This usually is the preferred approach to the treatment of cleft patients with missing laterals.
In a patient like Tina, because eruption of the canine will occur over the next few months, a prosthetic tooth may be attached to the acrylic of the retainer for esthetic purposes. In such a situation, the retainer must be adjusted regularly to clear the acrylic to allow the canine to erupt.
For some patients, the graft placement may be timed for the eruption of the lateral incisor near the cleft site (image 4). This tooth often is missing, but if it is present grafting is needed earlier—typically, at 6 to 7 years of age and certainly before the root is 2/3 formed—so that it erupts through the graft site. Having a tooth erupt through the grafted area is the key to obliterating the alveolar defect.
Therefore, to reemphasize, it is important to refer a cleft patient to the orthodontist by the time the permanent central incisors are erupting. Then the final decisions can be made on the timing of graft placement, and the need for pregraft orthodontic treatment. The family dentist should not assume that surely someone else is taking care of this.
 Image 1, treatment sequence |  Image 2, intraoral views: Tina, age 9-9, end phase 1. |
 Image 3, occlusal with retainer: Occlusal view, retainer in place. |  Image 4, early graft indication: Panoramic radiograph, lateral incisor developing: indication for early graft |
Adolescence/Early Permanent Dentition
Adolescence/Early Permanent Dentition
Despite all the treatment provided previously, adolescent cleft patients almost always have some combination of three problems: (1) posterior crossbite, (2) spacing/crowding, and (3) skeletal problems of the long face and/or maxillary deficiency types. As a result, a second phase of orthodontic treatment is needed once the permanent teeth have erupted (image 1). If the early surgeries have been atraumatic with minimal scarring, the patient will have a minor crossbite and reasonably normal midfacial growth. Then routine orthodontic treatment would be undertaken.
This was exactly the situation for Tricia, who had a right unilateral cleft of the lip and palate repaired as a baby and had an alveolar bone graft placed at age 9 1/2 years. She presented to her orthodontist at age 11 years with a convex profile, and a very mild midfacial deficiency and asymmetry of the alar rims (image 2). Intraorally (image 3), she had an increased overjet and overbite, transposed maxillary right canine and first premolar, a supernumary right maxillary lateral incisor, and crowding in both arches. Her maxillary left permanent first premolar had been extracted previously to relieve the crowding.
One consideration was the region of the grafted cleft site. Because the canine and first premolar were transposed—an uncommon situation—the first premolar erupted close to the supernumary lateral incisor. However, there was still space remaining. The orthodontist had to decide whether to extract the supernumary tooth and close the space by substitution of the premolar or reopen the space for a prosthetic lateral incisor. A decision like this is based largely on the morphology of the premolar crown and its suitability to serve as an esthetic replacement—but in fact, a premolar with the lingual cusp removed can look remarkably like a lateral incisor from the facial view. It should be noted that it is far more common for the canine to be substituted for the lateral incisor.
 Image 1, overview |  Image 2, full face and profile views: Facial appearance at age 11, after alveolar bone grafting at age 9, showing mild asymmetry of the nasal alae and a moderate skeletal Class II. |
 Image 3, occlusion: Intraoral views at age 11, after alveolar bone grafting. |
Adolescence/Early Permanent Dentition, cont’d.
The plan for Tricia was to extract the supernumary right lateral incisor and use the maxillary right first premolar as a lateral incisor, and finish with Class II molars. In addition, the mandibular arch was expanded to relieve the mild crowding.
Eruption of the premolar in the lateral incisor position completely obliterated the alveolar cleft site (image 1). At the end of orthodontic treatment, Tricia had excellent facial symmetry and balance (image 2). Intraorally, she finished with an ideal overjet and overbite and Class II molars (image 3). A Hawley retainer was used for retention in the maxillary arch and a bonded lingual retainer in the mandibular arch (image 4).
The lateral cephalometric radiograph (image 5) showed no evidence of maxillary deficiency, with slight elongation of face height and a mild skeletal Class II due to downward-backward rotation of the mandible. Superimposition of the pre- and posttreatment cephalograms show that little growth occurred during treatment. The major treatment change during this time was that the mandibular incisors were uprighted as the anterior crossbite tendency was corrected.
 Image 1, dental relationships during treatment: Tricia, age 12-4. Note the obliteration of the alveolar cleft with good dental health. |  Image 2, post-tretament facial views: Tricia, age 13-1, at the end of treatment. She has good facial esthetics, with no sign of maxillary deficiency. |
 Image 3, post-treatment occlusal views: Occlusion at the end of treatment. With closure of the space of the missing lateral incisors, a Class II molar relationship is necessary and functionally acceptable. |  Image 4, post-treatment dental relationships: Occlusal views. Note the reversed positions of the canine and first premolar |
 Image 5, post-treatment ceph and superimposition tracing: Lateral cephalometric radiograph showing a mild skeletal Class II jaw relationship and superimposition showing that minimal growth occurred during the period of treatment. |
Adolescence/Early Permanent Dentition, cont’d.
If the early surgeries resulted in enough scarring to significantly restrict growth, patients will have a greater midfacial deficiency and posterior crossbite, and orthognathic surgery to advance the maxilla and/or set back the mandible may be required (image 1). For these cases, orthodontics and orthognathic surgery are timed for late adolescence, when growth is essentially completed. This timing is important because surgery to reposition the jaws before facial growth is completed may be negated by later mandibular growth, so that a second surgery would be required later to correct the discrepancy. Generally, the age for surgery is between 16 to 18 years for females and 17 to 19 years for males.
This was the situation for Tina, whose phase 1 treatment we saw previously. Here she is at age 13 years 4 months (images 2, 3) . She had been followed without additional treatment after she discontinued the upper retainer at about age 11. By age 13, she was quite mature physically and in the permanent dentition. She was concerned about the appearance of her face and teeth, and anxious to get her treatment completed. Her chin was prominent and moderately deviated to the left, and the midface was deficient.
The maxillary left canine had erupted to the occlusal plane but remained to the lingual, out of the line of the dental arch. The lower incisors were mildly crowded and tipped lingually. The maxillary arch was V-shaped, quite narrow across the premolars and canines. With teeth missing in the upper but not the lower arch, the molar relationship needed to be Class II to provide normal occlusion, but the molars were Class I, and she had minimal overjet (image 4).
The panoramic radiograph showed normal bone in the alveolar cleft area, with the canine in that area having erupted down to the occlusal plane (image 5).
 Image 1, overview |  Image 2, full face / profile view: Tina, age 13-4, full face and profile. A skeletal Class III relationship exists. |
 Image 3, oblique facial views: The oblique facial views show the maxillary deficiency more clearly. |  Image 4, occlusion / alignment: The maxillary arch was quite V-shaped, constricted in the canine-premolar region, and she was in crossbite anteriorly and posteriorly as far as the first molars. |
 Image 5, panoramic radiograph: Note the excellent obliteration of the alveolar cleft, with good bone support for all teeth and good dental health. |
Adolescence/Early Permanent Dentition, cont’d.
Tina and her parents agreed that her concerns could not be met without orthognathic surgery. The plan was orthodontic treatment to align and coordinate the dental arches, while waiting for the completion of growth. The surgical plan was to advance the maxilla and set back the mandible more on the right than the left side, so as to bring the chin to the midline.
At age 14 years 6 months, because of her level of maturity and lack of recent growth, she was judged to be ready for surgery. Her maxillary deficiency and prominent/asymmetric chin were more apparent after the lower teeth were aligned and positioned properly relative to the mandible (images 1, 2). The maxillary arch had been expanded to make its arch form compatible with the lower arch and the teeth in both arches aligned. The maxillary canines now substituted bilaterally for the missing maxillary lateral incisors (image 2). The cephalometric radiograph shows the extent of her skeletal Class III problem (image 3). A superimposition tracing from the beginning of phase 1 treatment (solid lines) shows the downward but not forward growth of the maxilla, with considerable downward-forward growth of the mandible during adolescent growth (image 4).
A note of caution: Surgical advancement of the midface in a cleft palate patient can result in leakage of air through the nose during speech, creating nasal “cleft palate speech” that was not present previously. This occurs because as the hard palate moves forward along with the rest of the maxilla, the soft palate is pulled forward and away from the pharyngeal wall. The potential for speech problems should be investigated by the craniofacial team before maxillary advancement surgery. For some patients, moving the deficient maxilla forward has such a positive effect on facial esthetics that it is worth doing even if secondary pharyngeal surgery to control speech problems might be necessary afterward. Tina was judged to be a minimal risk for speech problems.
 Image 1, facial views: Tina, age 14-4, presurgery. |  Image 2, intraoral views: Tina, age 14-4, presurgery. |
 Image 3, presurg ceph: Tina, age 14-4, presurgery. |  Image 4, superimposition tracing: Lateral cephalometric superimpositions show the Class III growth pattern from age 7 to 14, with downward growth of the maxilla and downward-forward growth of the mandible. |
Adolescence/Early Permanent Dentition, cont’d.
At surgery, a LeFort I osteotomy was used to move the maxilla forward with onlay graphs to the maxilla, and the mandible was moved back more on the left than the right sides (image 1). The screws and plates used for rigid internal fixation can be seen in the postsurgical radiograph. The cephalometric superimposition (image 2) shows the forward movement of the maxilla, with downward rotation anteriorly to increase the display of the maxillary incisors, and moderate backward movement of the chin.
Finishing orthodontics began 4 weeks postsurgery, and flexible arch wires and light elastics were used to bring the teeth into final occlusion (image 3). The braces were removed 3 months later, at age 14 years 10 months (image 4), with a Class II molar relationship because of the maxillary space closure but good occlusion.
 Image 1, pre/postsurg cephs: Cephalometric radiographs before/after orthognathic surgery. |  Image 2, superimposition tracing: Superimposition tracing before/after orthognathic surgery. |
 Image 3, finishing orthodontics: Intraoral views showing the typical use of light vertical elastics postsurgically to help the patient learn to function in the new jaw relationship. |  Image 4, braces off: Dental alignment/occlusion at the completion of treatment. The maxillary canines have been shaped to simulate lateral incisors. |
Adolescence/Early Permanent Dentition, cont’d.
Comparison of facial views before and after surgery make the improvement in her facial proportions clearly evident (images 1-3).
At the completion of phase 2 orthodontics (with or without orthognathic surgery), surgery to improve the esthetics of the lip and nose and to correct any residual distortions and asymmetries in these regions is considered. For Tina, it was not necessary.
On 2-year recall (image 4), there was slight transverse collapse of the maxilla and a mild posterior crossbite tendency, but the dental alignment and skeletal relationships were nicely maintained. She enjoyed an active social life and was quite pleased with the outcome of treatment.
 Image 1, smile view: Tina, age 14-4 presurgery and age 16-9, 2-year recall. |  Image 2, oblique view: Tina, age 14-4 presurgery and age 16-9, 2-year recall. |
 Image 3, profile view: Tina, age 14-4 presurgery and age 16-9, 2-year recall. |  Image 4, dentition, 2 year recall: Tina, age 16-9, 2-year recall |
Summary
Summary
In summary, patients with cleft lip and palate require numerous treatments during the first 20 years of life, which are summarized in the accompanying image.
Treatment procedures required by every patient are shown in yellow; procedures that may or may not be needed are shown in white. To maximize the benefits and minimize any negative consequences, it is important to properly sequence the various treatments. Obtaining an alveolar bone graft before the permanent teeth erupt in that area is particularly important and is something that the family dentist should keep in mind, especially if the patient’s family is not in close contact with a cleft palate team at that time.
Coordination of treatment among the group of specialists who are needed in the treatment of a cleft patient is best achieved by a cleft palate team. Such a team, a group of specialists who work together for short- and long-term treatment planning, exists in most metropolitan areas, usually in connection with the local dental school or, if there is no school, a major local hospital. Patients who are not being followed by a team should be referred to one in your area.
In this review you have been provided with the sequencing of treatments from a general perspective. It must be emphasized that your responsibility is to provide treatment that is in compliance with the team’s recommendations, and for this, you must keep in contact with the team. All teams provide their members, and those doctors participating in the care of their patients, with reports that are generated after each patient’s visit to the team. Recall that patients visit the team on a regular basis for follow-up—generally either annually or biannually. You, as the general dentist, should feel comfortable contacting either the team coordinator, director, or any member on the team for clarification of treatment and advice concerning the management of your patient.
Self-Test Referral
The self-test section of this program is designed to help you be sure you have understood the material. Take it now, and use it as a guide for further study and review.
Copyright 2003, UNC Dept. of Orthodontics
Self-Test
Question 1
A) Surgery to repair a cleft of the secondary palate causes a deficiency of the midface because B) During the surgery bone is placed in the hard palate to close the defect.
- A true, B true, A and B related
- A true, B true, A and B not related
- A true, B false ✓
- A false, B true
- A and B false
Correct
That’s right, the surgery to repair the palatal cleft involves lifting soft tissue flaps from the palatal halves and suturing the flaps in the midline. No bone is placed in the secondary palate during the repair. This surgery causes scarring of the tissues, which restricts the growth of the maxilla, thus a midfacial deficiency results. The extent of the scarring depends on the quality of the surgery—the less traumatic the surgery, the less the extent of midfacial deficiency.
Incorrect
No that’s wrong. The surgery to repair the palatal cleft involves lifting soft tissue flaps from the palatal halves and suturing the flaps in the midline. No bone is placed in the secondary palate during the repair. This surgery causes scarring of the tissues, which restricts the growth of the maxilla, thus a midfacial deficiency results. The extent of the scarring depends on the quality of the surgery—the less traumatic the surgery, the less the extent of midfacial deficiency.
Question 2
A) Alveolar bone grafting in the mixed dentition is always timed for the eruption of the lateral incisor because B) This tooth is most likely to be present near the cleft site.
- A true, B true, A and B related
- A true, B true, A and B not related
- A true, B false
- A false, B true
- A and B false ✓
Correct
That’s right, an alveolar bone graft is generally timed for the eruption of the canine near the cleft site but may also be timed for the eruption of the lateral incisor, if present. Often, however, the lateral incisor near the cleft site is missing or so malformed that it requires extraction, so it is not the most likely tooth to be present near the cleft site.
Incorrect
No, that’s wrong. An alveolar bone graft is generally timed for the eruption of the canine near the cleft site but may also be timed for the eruption of the lateral incisor, if present. Often, however, the lateral incisor near the cleft site is missing or so malformed that it requires extraction, so it is not the most likely tooth to be present near the cleft site.
Question 3
To ensure the proper timing of placement of the alveolar bone graft, it is important for the general dentist to refer a child with an alveolar cleft to the orthodontist at which of the following stages?
- Soon after birth
- Once the deciduous teeth have erupted
- Just as the maxillary central incisors are erupting ✓
- In the mixed dentition
- In the permanent dentition
Correct
That’s right, a child with a cleft of the alveolus should be referred to the orthodontist just as the maxillary permanent central incisors are erupting. Referral at this time would ensure that the orthodontist has sufficient time to assess the child’s eruption status. The orthodontist will determine whether there is a viable lateral incisor near the cleft site that would require grafting at that time, or whether the graft could be placed later because the lateral is missing.
Incorrect
That’s wrong. A child with a cleft of the alveolus should be referred to the orthodontist just as the maxillary permanent central incisors are erupting. Referral at this time would ensure that the orthodontist has sufficient time to assess the child’s eruption status. The orthodontist will determine whether there is a viable lateral incisor near the cleft site that would require grafting at that time, or whether the graft could be placed later because the lateral is missing.
Question 4
A) Orthodontic treatment in the patient with a repaired cleft of the lip and palate is generally needed during the primary dentition because B) The collapsed maxillary arch must be expanded as early as possible to ensure stability.
- A true, B true, A and B related
- A true, B true, A and B not related
- A true, B false
- A false, B true
- A and B false ✓
Correct
That’s correct, generally it is a waste of time to start orthodontic treatment in the primary dentition. Expanding the maxillary arch at this time is not necessary and certainly will not ensure stability of the expansion. A retainer must be used to hold the expansion. An initial phase of orthodontics occurs in the early mixed dentition in conjunction with alveolar bone grafting. Then, there is a second phase of orthodontics once the permanent teeth erupt during adolescence.
Incorrect
That’s wrong. Generally it is a waste of time to start orthodontic treatment in the primary dentition. Expanding the maxillary arch at this time is not necessary and certainly will not ensure stability of the expansion. A retainer must be used to hold the expansion. An initial phase of orthodontics occurs in the early mixed dentition in conjunction with alveolar bone grafting. Then, there is a second phase of orthodontics once the permanent teeth erupt during adolescence.
Question 5
A) Palate repair in a patient with a cleft of the secondary palate should be delayed until at least age 2 because B) Delaying surgery to the secondary palate allows the tissues to mature and enhances the development of speech.
- A true, B true, A and B related
- A true, B true, A and B not related
- A true, B false
- A false, B true
- A and B false ✓
Correct
That’s right, both statements are false. There is a trade-off between the speech pathologist versus the surgeon and orthodontist regarding the timing of palatal closure. The surgeon and orthodontist would like the surgery delayed to allow sufficient development and maturation of the hard and soft tissues to facilitate the surgical repair and decrease the chance of impaired maxillary growth; however, the surgery is not delayed until at least age 2 years. It is generally performed around one year of age. This is because surgical techniques have improved and the chance of growth problems have decreased. Delaying the surgery does not enhance the development of speech; in fact, speech development is enhanced the earlier the surgery is performed.
Incorrect
That’s wrong. There is a trade-off between the speech pathologist versus the surgeon and orthodontist regarding the timing of palatal closure. The surgeon and orthodontist would like the surgery delayed to allow sufficient development and maturation of the hard and soft tissues to facilitate the surgical repair and decrease the chance of impaired maxillary growth; however, the surgery is not delayed for as long as possible. It is generally performed around one year of age. This is because surgical techniques have improved and the chance of growth problems have decreased. Delaying the surgery does not enhance the development of speech; in fact, speech development is enhanced the earlier the surgery is performed.
Question 6
Which one of the following statements is true about a presurgical infant orthopedic appliance?
- It is primarily a feeding appliance.
- It is used before palate repair to mold the maxillary arch.
- It is used to enhance speech development.
- It is a pinned appliance.
- It is used before lip repair to mold the maxillary segments. ✓
Correct
That’s right, a presurgical infant orthopedic appliance is used to mold the maxillary cleft segments restoring symmetry to the arch before the lip is repaired. The appliance is made at the request of the surgeon, and after the lip is repaired, it is removed. It is not a feeding appliance. With proper instructions to the mother, the baby can feed effectively without an appliance. The orthopedic appliance does not enhance speech, and depending on the design, the appliance may or may not be pinned to the maxilla.
Incorrect
That’s wrong. A presurgical infant orthopedic appliance is used to mold the maxillary cleft segments restoring symmetry to the arch before the lip is repaired. The appliance is made at the request of the surgeon, and after the lip is repaired, it is removed. It is not a feeding appliance. With proper instructions to the mother, the baby can feed effectively without an appliance. The orthopedic appliance does not enhance speech, and depending on the design, the appliance may or may not be pinned to the maxilla.
Question 7
A) The key to the obliteration of an alveolar cleft is to have the tooth near the cleft site erupt thorough the graft because B) An erupting tooth causes complete remodeling and replacement of bone in the area through which it erupts and this process provides the erupting tooth with sound periodontal support.
- A true, B true, A and B related ✓
- A true, B true, A and B not related
- A true, B false
- A false, B true
- A and B false
Correct
That’s right, an alveolar cleft will be successfully obliterated when the tooth near the cleft site, for which the graft placement was timed, erupts through the grafted area and causes complete remodeling and replacement of bone. This eliminates the bony defect and provides the erupting tooth with sound periodontal support.
Incorrect
That’s wrong. An alveolar cleft will be successfully obliterated when the tooth near the cleft site, for which the graft placement was timed, erupts through the grafted area and causes complete remodeling and replacement of bone. This eliminates the bony defect and provides the erupting tooth with sound periodontal support.
Question 8
Which of the following is the most likely speech problem to result from maxillary advancement surgery in a patient with a cleft palate?
- Leakage of air through the nose (hypernasal speech) ✓
- Labiodental articulation problems
- Blockage of air passage through the nose—hyponasal speech
- Lisping
Correct
That’s right, the most likely speech problem to result from maxillary advancement surgery in a patient with a cleft palate is leakage of air through the nose during speech, or hypernasal speech. This occurs because as the hard palate moves forward along with the rest of the maxilla, the soft palate is pulled forward and away from the pharyngeal wall, which requires greater movement of the soft palate and pharyngeal wall to prevent excess air flow through the nose. After surgery to repair a cleft, movement of the soft palate is restricted, and then moving it forward can lead to inappropriate leakage of air.
Incorrect
That’s wrong. The most likely speech problem to result from maxillary advancement surgery in a patient with a cleft palate is leakage of air through the nose during speech, or hypernasal speech. This occurs because as the hard palate moves forward along with the rest of the maxilla, the soft palate is pulled forward and away from the pharyngeal wall, which requires greater movement of the soft palate and pharyngeal wall to prevent excess air flow through the nose. After surgery to repair a cleft, movement of the soft palate is restricted, and then moving it forward can lead to inappropriate leakage of air.
Question 9
A) For patients who have a cleft of the lip and/or palate the standard of care requires a team approach to the management of their care because B) Team treatment improves efficiency of care (patients do not have to visit several offices) and ensures coordinated treatment.
- A true, B true, A and B related ✓
- A true, B true, A and B not related
- A true, B false
- A false, B true
- A and B false
Correct
That’s right, the current standard of care for patients with a cleft of the lip and/or palate requires that a team approach to treatment is used with the various specialists on the team interacting together to ensure timely, efficient, and coordinated care for the patients. This is important because of the many different treatment needs of these patients.
Incorrect
That’s wrong. The current standard of care for patients with a cleft of the lip and/or palate requires that a team approach to treatment is used with the various specialists on the team interacting together to ensure timely, efficient, and coordinated care for the patients. This is important because of the many different treatment needs of these patients.
Question 10
A) Orthognathic surgery for a patient with a repaired cleft of the lip and/or palate is timed for late adolescence when growth is essentially completed because B) The patient is more likely to tolerate surgical treatment at this time.
- A true, B true, A and B related
- A true, B true, A and B not related
- A true, B false ✓
- A false, B true
- A and B false
Correct
That’s right, orthognathic surgery for a patient with a repaired cleft of the lip and/or palate is timed for late adolescence when growth is essentially completed because if the surgery is done earlier, before facial growth is completed, the outcome may be negated by later mandibular growth so that a second surgery would be required to correct the discrepancy. Tolerance for surgery is specific to the particular patient and may or may not be an age-related factor.
Incorrect
That’s wrong. Orthognathic surgery for a patient with a repaired cleft of the lip and/or palate is timed for late adolescence when growth is essentially completed because if the surgery is done earlier, before facial growth is completed, the outcome may be negated by later mandibular growth so that a second surgery would be required to correct the discrepancy. Tolerance for surgery is specific to the particular patient and may or may not be an age-related factor.