Orthodontic Management In Cleft Patients

1. Define and classify orofacial clefts

Cleft lip
 Failure of fusion between median nasal process and maxillary process
 Failure of mesodermal migration between two layered epithelial membrane
which results due to fusion between the 2 processes
 It will lead to breakdown and cleft formation
Cleft palate
Normal development
 At 7 weeks of iu life – 2 palatal shelves from maxillary process lie vertically
on either side of tongue
 Between 8-9 weeks of iu life, tongue drops down due to stomotodeum and
extension of head
 Then palatal shelves become free and swing into horizontal place
Development cleft
 Alterations of intrinsic palatal shelf force (
 Failure of tongue to drop down
 Non fusion of the shelves
 Fusion of the shelves with subsequent breakdown to inadequate breakdown to
inadequate mesodermal migration
Primary palate- maxilla with 4 incisor teeth
Secondary palate- other than above
2. Problems faced by CLP patients

Problems Explanations

Cleft lip- Inability to suck on nipple

Cleft palate- mild to be accidentaly uptake into nasal cavity or chocking
Feeding
Inability to create negative pressure inside oral cavity, regurgitations
Difficulty feeding – impact growth & readiness for corrective surgeries

Aesthetic Deformity of the dentition, lip and nose

Hearing Impaired hearing because middle ear effusion

Speech Resonance disorders, articulation errors & expressive language delay

 Malalignment, Delayed eruption, Anomalies of morphology and number
Dental
Impact growth of facial bone

Psychology Psychosocial impact to the child and family

Dental problems
Localized problem Orthodontic problem
 Congenital missing teeth (lateral/  Class III malocclusion
canine)  Class III skeletal problem
 Hypodontia, hyperdontia, oligodontia  Anterior and posterior crossbite
 Presence of natal and neonatal teeth  Spacing and crowding
 Microdontia, macrodontia
 Fused teeth
 Enamel hypoplasia
 Poor periodontal support
 Early loss of teeth
 Germination, dilacerations

Class III skeletal problem as maxilla stop to growing due to scaring of the surgery and
mandible grow normally

Age Treatment

Dental Counselling, Feeding plate or Pre-surgical orthopaedics (if

Birth to 6 mo
indicated)

6 mo to 1 years Introduce parents dental care for the primary teeth

old Diet advice & Behaviour management

Preventive measures : Fluoride application, Fissure sealant, Oral hygiene

Care
1 to 6 years old Monitor any dental abnormalities : Supernumerary, missing teeth
Restorative or extractions treatment (if indicated)
Regular monitoring

Paeds Dental : Monitor and maintain good oral health

6 to 10 years Orthodontist : Orthodontic consultation (8-10 years old: mixed
old dentition)
OMFS : Alveolar Bone Graft assessment

10 to 16 years Paeds Dental : Preventive, Restorative, Extractions, Interceptive

old Orthodontics
Orthodontist : Fixed appliances (13-17 years old: permanent
 dentition)
OMFS : Alveolar Bone Graft Surgery

General Dental Care

17 years old
Orthodontist : Pre-orthognathic Surgery orthodontics
and above
OMFS : Orthognathic Surgery

3. Role of orthodontist

1) Pre-surgical orthopaedics
- Partial obturation to aid in feeding
o Maxillary strapping or lip tapping
 Act as active component with the passive plate to approximate the
alveolar segments
 Bring the lip segments together
 Taping the lips together helps to upright the inclined columella
along the midsagittal plane
o Nasoalveolar moulding appliance
 Reduce severity of initial cleft
 Reduction in the width of the alveolar cleft segments until passive
contact of the gingival tissues is achieved
- This is to reduce the size of cleft defect and to aid in surgery
- Repositioning of nasal cartilages, columella, nasal tip and lateral wall of vestibule

2) Correction of anterior crossbite in mixed dentition (8-10 years old)

- UI erupt into palatally and commonly displaced or rotated
- Upper arch expansion before ABG
o Usually quadhelix for around 6-12 months
o To create better surgical access for the surgeon so maximum amount of
bone can be placed

3) Preparation of maxillary arch for alveolar bone graft and maxillary

expansion
Secondary bone grafting
- Before eruption of permanent canine
- Root of canine1/3 to 2/3 formed
- Age between 8-11 years old
- Take form iliac crest
Benefit of secondary alveolar bone grafting
- Stabilization of maxillary arch
- Continuation of maxilla and arch form
- Closure of vestibule and palatal oronasal fistula
 - Provision of sufficient bone quantity and quality to allow eruption of permanent
lateral incisor and canine teeth
- To provide better periodontal support for teeth order to cleft
What happen if the surgery is late?
- The root is fully formed and cannot erupt normally need to do ortho traction

4) Orthodontic treatment for permanent dentition and orthognathic surgery during

adolescence

Orthodontic treatment only Fixed appliances to straighten the teeth alignment and where possible, to
close all residual spaces without the use of dentures, bridges or implants.

Orthodontic treatment
Prosthodontic work involves in replacing the missing tooth/teeth by using
finishing with prosthodontic
dentures, bridges or implants.
work

Orthodontic treatment with Pre-orthognathic orthodontics. Then, orthognathic surgery may be carried
orthognathic surgery out when a CLP individual is near the completion of growth, usually at 18
years old.

Orthodontic treatment,
orthognathic surgery and
prosthodontic work

Orthognathic surgery in cleft patients

- Surgical advancement of the maxilla may affect velopharyngeal function therefore
a speech assessment should be carried out before planning surgery
- Scar tissue may restrict the amount of forward movement of the maxilla that is
possible
- Reduced blood supply to the maxilla due to scarring
- Maxillary distraction may overcome these problems