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CHAPTER 7
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FUNDAMENTAL POINT 3
Sequence ofTreatment forCleft Lip andPalate
Initial Care
• Prenatal diagnosis and consultation should be
followed by the establishment of cleft team care
• Presurgical maxillary orthopedics to improve the
position of the maxillary alveolar segments and/or
enhance the nasolabial esthetic outcomes prior to
surgical closure of the cleft lip may be indicated for
some infants
Primary Cleft Lip/Palate Surgery
• Surgical repair of the cleft lip is usually initiated
within the first 12 months of life and may be
performed as early as is considered safe for the
infant. The goal of cleft lip repair is to restore the
normal function and anatomical features
It is highly recommended that an experienced
•
pediatric anesthesiologist must be present for all
surgical procedures involving children
• Depending on the severity of the nasal defect,
primary rhinoplasty may be performed at the time
of the primary cleft lip repair
• A preliminary cleft lip adhesion is a procedure that
may be used in selected patients preceding
definitive cleft lip repair
• Primary surgery can also include alveolus at a
minimum of 10 weeks (rule of 10: 10 lb, 10 weeks,
10 g hemoglobin), averaging between three and six
months of age
• In the typically developing child, the cleft palate is
closed by the age of 18 months, with average
closure occurring around one year. The goal of cleft
palate surgery is to achieve normal function for
speech and swallow. Earlier closure, when possible, is preferable in order to avoid speech
impairments
•
Patients with submucous cleft palate should
bemonitored closely, and repaired only if there
isevidence of feeding, otologic, or speech
problems
Secondary Cleft Lip/Palate Surgery
• Many patients will require secondary surgical
procedures involving the lip, nose, palate, and
jaws. These procedures usually are staged from
infancy through adulthood
• Secondary cleft lip/palate surgery or surgery for
velopharyngeal dysfunction should be performed
only after evaluation (imaging) of the velopharyngeal
mechanism during speech. Input from speech–language pathology and other team members should
be obtained prior to this surgery
Tonsillectomy and/or adenoidectomy may also be
•
indicated to permit safe performance of a pharyngeal flap or other type of pharyngoplasty
• Surgical or prosthetic closure of palatal fistulae may
be needed if the fistulae are symptomatic
• The timing of bone grafting of the alveolar cleft
should be determined by the stage of dental development. Ideally, the graft should be placed before
the eruption of the permanent maxillary teeth, age
6–12 years, in the region of the cleft. Thetiming of
the operative procedure should be determined in
collaboration with the team orthodontist.
Autogenous bone should be used when tooth
movement through the graft is anticipated
• Although rhinoplasty and nasal septal surgery are
usually advocated only after completion of nasal
growth, earlier intervention for reasons of airway
problem or nasal tip difference may be indicated.
Repair of the cleft lip nasal difference can be accomplished with limited external incisions on thenose
(ACPA 2018b)
K. Comprehensive Treatment Plan
• Due to compliance and success with a
specializedfeeding bottle, no obturator
was needed
• DynaCleft lip tape (Southmedic, Barrie, ONT,
Canada) and nasal elevator placement
(Figure7.6.4)
• Cleft lip/nose repair at two to three
monthsofageandcleft palate repair at 10–12 months
of age
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• Comprehensive dental visit with a pediatric dentist by
one year of age
• Appropriate follow‐up with interdisciplinary team
L. Intra‐ andPostoperative Images
• See Figures 7.6.5 and 7.6.6
M. Prognosis andDiscussion
• DynaCleft and lip taping was chosen because of
patient and parent compliance and the need for less
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GROWTH ANDDEVELOPMENT
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Figure 7.6.4 Patient after DynaCleft and nasal elevator placement.
Figure 7.6.6 Patient one year postoperative cleft lip and palate
repair.
Figure 7.6.5 Patient one week postoperative cleft lip repair.
follow‐up visits. This approach was selected over
nasoalveolar molding which requires frequent
follow‐up visits and Latham appliance which is
invasive and requires placement under general
anesthesia
• Lip taping can be successful as it prevents the
tongue, bottle, and digits from entering the area of
the cleft, minimizing pressure and movement in the
area of the cleft. Lip taping mimics as a nonsurgical
lip musculature to aid in the orthopedic manipulation
of the tissues
The overall result was excellent. Appropriate lip and
•
nasal approximation and healing were achieved
• Overall prognosis is good. However, the risk for
malocclusion is high and there is a potential for
anterior and posterior crossbite. Also, there is a risk
for tooth agenesis, supernumerary teeth, and/or
malformed teeth in the area of the cleft. In addition,
there is a higher caries risk with contributory poor
oral hygiene. Therefore, follow‐up for anticipatory
guidance and prevention with a pediatric dentist is
highly recommended. It is also essential that the
parents follow through with recommended orthodontic evaluations at an early age. Parents should be
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provided resources for information (see online
resource: https://cleftline.org/family‐resources/
booklets‐fact‐sheets)
N. Complications andAlternative
TreatmentPlan
• Lip scarring and/or malalignment and malpositioning
of teeth can make the cleft area more difficult to
clean and access
• Parents are often overwhelmed by the medical needs
of the child which can result in oral health status
having a low priority
• Enamel defects or hypoplasia of teeth in or adjacent
to the cleft site
• Potential oral aversion and/or fear of tooth‐brushing
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Self‐Study Questions
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GROWTH ANDDEVELOPMENT
1. How common is cleft lip and palate?
2. What teeth are most commonly congenitally
absent in patients with cleft lip and palate?
3. What are some of the variations in tooth morphology commonly seen in complete unilateral or
bilateral clefts of the palate?
4. Definitive surgical lip closure and palatal surgery
can result in what?
5. Why is closure of the palate typically accom-
plished by one year of age?
Answers are located at the end of the case
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Self‐Study Answers
1. Cleft lip and palate are the most common of the
craniofacial anomalies and have an incidence of
0.28–3.74 per 1000 live births globally. In the United
States, cleft lip and palate occur in approximately
one in 940 newborns (Parker etal. 2010)
2. The maxillary primary or permanent lateral incisor, adjacent to the alveolar cleft. There is also an
increased incidence of congenitally missing second
premolars and supernumerary teeth
3.
Enamel hypoplasia, microdontia, macrodontia,
fused teeth, agenesis, supernumerary and aberrations in crown shape are all possibilities to be seen
in patients with cleft lip and palate
Bibliography
American Academy of Pediatric Dentistry. 2018–2019. Policy on
the management of patients with cleft lip/palate and other
craniofacial anomalies. In: Clinical Practice Guidelines and
Best Practices (Reference Manual). Pediatr Dent 40:429–30.
https://www.aapd.org/research/oral‐health‐policies‐‐
recommendations/management‐of‐patients‐with‐cleft‐
lip‐palate‐and‐other‐carniofacial‐anomalies
American Cleft Palate–Craniofacial Association. 2018a. Standards
for Approval of Cleft Palate and Craniofacial Teams. https://
acpa‐cpf.org/team‐care (Accessed 19 June 2019).
Maxillary arch collapse in unilateral or bilateral
4.
complete cleft may occur. Anterior and posterior
crossbite can also be present. The debate is ongoing on the extent of the effect the palatal scar can
have on maxillary constriction and midface deficiency. There is also debate as to the effect of the
lip scar and resulting tension on the maxillary arch
architecture and constriction
5. To facilitate the acquisition of normal speech,
because this correlates with the age at which most
children begin speech development, usually age
6–12 months
American Cleft Palate–Craniofacial Association. 2018b.
Parameters for Evaluation and Treatment of Patients with
Cleft Lip/Palate or Other Craniofacial Differences. Revised
edition. https://acpa‐cpf.org/team‐care/standardscat/parameters‐
of‐care (Accessed 19 June 2019).
Parker SE, Mai CT, Canfield MA et al.; National Birth Defects
Prevention Network. 2010. Updated National Birth Prevalence
estimates for selected birth defects in the United States, 2004–
2006. Birth Defects Res A Clin Mol Teratol 88(12):1008–16.
Wells M. 2013. Oral health status of children with craniofacial
anomalies. Pediatr Dent 35(3):E79–86.
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Case 7
Orthodontics forPatient withCleft LipandPalate
AB C
Figure 7.7.1 Pretreatment photograph. (A) Profile; (B) frontal; (C) smile.
A. Presenting Patient
• Nine‐year‐old male Caucasian (Figure7.7.1)
B. Chief Complaint
• Remaining cleft of the right maxillary alveolus and fistula
C. Social History
• The patient is well developed
• Lives with parents
• Very active in school activities
• Middle class socioeconomic status
D. Medical History
• Right unilateral complete cleft lip and palate
(repaired)
Review of systems: asthma, controlled
Medications: albuterol as required
Allergies: none
• Surgical history:
Primary cleft lip and nose repair
Primary hard palate repair
Secondary nasal revision
E. Medical Consult
• The patient is followed on an annual basis by the local
cleft/craniofacial anomalies team. This team consists
of multiple medical and dental specialty providers
focused on treatment of patients with cleft and
craniofacial anomalies. During the patient’s team visits,
next steps in cleft care are discussed and determined
with all team members as well as the family
F. Dental History
• Has a dental home where he receives regular oral
health care on a six‐month recall schedule
• Previous restorative care
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FUNDAMENTAL POINT 1
Oral Health inPatients withClefts
• Every patient with a cleft should have established care,
evaluation, and follow‐up with a cleft team (see Case 6
for more information about interdisciplinary teams). It
is still important to retain a dental home in addition to
seeing the cleft team specialists
• With the higher caries risk and incidence in
patients with a cleft and the need for early orthodontic intervention, it is critical that the patient be
seen early and more frequently by a pediatric
dentist and orthodontist
• Caries prevention is essential. Early, frequent, and
continued interaction with the pediatric dentist can
facilitate parent education, dietary consultation,
oral hygiene instructions for the parent and child,
and other preventive measures
Maintenance of primary teeth is imperative for
•
several reasons: they act as space maintainers
(due to potential of missing teeth), bone is
preserved by primary teeth bordering the area of
the cleft, and they provide anchorage for early
orthodontic appliances and intervention
• Avoid extraction of primary teeth bordering the
cleft. Ideally, it is best to retain them when possible or prolong with interim treatment unless
infection and abscess are present (see Chapter1,
Case 4 on Silver Diamine Fluoride and Chapter3,
Cases 3 and 4 on Pulp Therapy in Primary Teeth).
Any extractions should be timed and coordinated
with orthodontic consultation prior to doing so.
Timing can be affected due to placement of
orthodontic appliances or timing of alveolar bone
grafting
• When possible, any other dental treatment should
be performed at the same time as any other cleft
surgeries to minimize the amount of time in the
operating room and under general anesthesia
(American Cleft Palate–Craniofacial Association
[ACPA] 2018)
G. Extraoral Exam (Figure7.7.1)
• Facial balance within normal limits
• Lack of incisal display on smile
• Asymmetric alar base
H. Intraoral Exam (Figure7.7.2)
• Early mixed dentition
A
D
• Missing maxillary right permanent lateral incisor and
mandibular right permanent lateral incisor
• Existing restorations in mandibular primary molars
• Traumatic occlusion with gingival irritation on maxillary right permanent central incisor
B
E
C
Figure 7.7.2 (A–E) Pretreatment intraoral photographs showing cleft of the alveolus and anterior crossbite.
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BACKGROUND INFORMATION 1
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Oral Manifestations andCleft Lip andPalate
• Higher caries risk in both primary and permanent dentition, increased periodontal disease,
and poor oral hygiene. Oral hygiene risk factors
can be increased due to: malocclusion, malposition of the teeth in the area of the cleft, tension
on the tissue from lip scar which can restrict
access to the teeth in the area of the cleft,
enamel hypoplasia, early orthodontic appliance
wear, food impaction, and apprehension of
parents to brush near the cleft site
• Dental anomalies seen can include: agenesis,
supernumerary and/or malformed teeth in the
area of the cleft
Before the primary dentition is completed, the
•
skeletal and dental components should be
evaluated to determine if a malocclusion is
present or developing. Regular, ongoing contact
should be maintained with the orthodontist to
monitor growth, position, and size of the skeletal
and dental components, allowing for the determination of the optimal time for intervention
• Ongoing interaction between the cleft team and
the dental providers provides the opportunity for
input regarding changes in: the patient’s behavior, sleep, academic performance, and social
interactions. They may also assist in referrals to
a maxillofacial surgeon, periodontist, and
prosthodontist as necessary
(ACPA 2018)
I. Diagnostic Tools
• Extraoral and intraoral photographs
• Cone beam computed tomography (CBCT) utilized
forscan
• CBCT was used to create lateral cephalogram and
panoramic images (Figure7.7.3)
• Alginate impressions to create study models
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Class I skeletal, class II division II dental
• Cleft of the maxillary right alveolus
GROWTH ANDDEVELOPMENT
Problem List
•
Unrepaired cleft of the maxillary right alveolus
• Minor transverse collapse of right (lesser) segment of
the maxillary arch
• Class II division II early mixed dentition
• Missing permanent maxillary right lateral incisor
• Missing permanent mandibular right lateral incisor
• Single tooth anterior crossbite
• Traumatic occlusion associated with 100% overbite
FUNDAMENTAL POINT 2
Bone Grafting
• Bone grafting is a procedure which involves
taking a small amount of bone (usually
harvested from the hip, head, ribs, or leg) and
placing it in the area of the cleft near the teeth
The procedure has four goals:
•
To provide support for unerupted teeth and
teeth next to the cleft
To provide support for the lip and nose and to
improve symmetry
To form a continuous maxillary alveolar ridge,creating stability and a more natural appearance
To improve the stability of the premaxilla if a
bilateral cleft is present
• Timing of the alveolar bone graft should be
coordinated between the orthodontist and the
surgeon and should be determined by the stage
of dental development. Ideally, the graft should
be placed before the eruption of permanent
maxillary teeth in the region of the cleft. If the
bone graft is placed after the permanent teeth
have erupted there may be inadequate bony
support for the teeth near the cleft
•
Once the bone graft has been placed, there are
three options to replace any missing teeth in the
area of the graft:
Orthodontic movement of adjacent teeth into
the bone graft
Prosthetic replacement (dental bridge)
Dental implants
(ACPA 2018)
Comprehensive Treatment Plan
L.
• Phase one orthodontics in preparation for alveolar
bone grafting (Figure7.7.4)
Limited maxillary expansion with quad helix
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AB C
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Figure 7.7.3 Pretreatment cone beam computed tomography‐
derived panoramic image.
A
B
Figure 7.7.4 Prealveolar bone grafting orthodontic brackets.
Note the maxillary quad helix expander (A) and the corrected
anterior crossbite (B).
Prealveolar bone grafting orthodontic brackets
– Eliminate traumatic occlusion
– Maintain mesial root position of the maxillary
right central incisor
– Coordinate timing of expansion with surgeon/
surgical timeline for alveolar bone graft
Alveolar bone graft
– To facilitate eruption of maxillary canine into the
area of the cleft and maintain a healthy position
for the mesially tipped root of the maxillary right
central incisor
– Three months healing time
Orthodontic finish and detailing
– Correct root orientation of maxillary right central
incisor by repositioning bracket
– Open space for missing permanent maxillary right
lateral incisor
Figure 7.7.5 Facial photographs, 15 months after treatment
initiation. (A) Profile; (B) frontal; (C) smile.
– Close space for missing permanent mandibular
right lateral incisor
Final retention
– Hawley retainer with pontic tooth in the position
of missing maxillary right lateral incisor
• Monitoring of growth to determine start of phase two
orthodontic treatment
• Caries prevention plan with dental home and three‐
month recall visits
M. Intraoperative Images
• Intraoral images prior to bone graft (Figure7.7.4)
N. Final Images
• Fifteen months after initial orthodontic bonding
(Figures7.7.5–7.7.7)
O. Prognosis andDiscussion
• The overall result and prognosis for this patient was
good. He has adequate bony support in the maxilla
to support eruption of the developing canine and
support proper positioning of the right central
incisor. His skeletal relationship in an anteroposterior, vertical, and transverse dimension is well
balanced. His growth will be monitored for future
orthodontic needs as well as prosthetic dental
replacements
Complications andAlternative
P.
TreatmentPlan
• If bone grafting fails, orthodontic tooth movement
through the cleft site would be delayed until a
successful graft was completed
• Often clefts of the palate or alveolus can have
associated oronasal fistulas
• Closure of the fistula will usually occur during
bonegrafting
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A
D
Figure 7.7.6 (A–E) Intraoral photographs, 15 months after treatment initiation (postalveolar bone grafting).
B
E
C
bonded RPE when a considerable amount of expansion is necessary. Also, expansion can be achieved
surgically using distraction osteogenesis and LeFort/
orthognathic surgery
In this case, due to the traumatic occlusion, bonded
•
brackets were placed prior to surgery. In some cases, it
may not be necessary to bracket presurgically but rather
wait until the patient has healed from surgery and
minimize risk of root movement into an unrepaired cleft
• Orthognathic surgery may be indicated if orthodontic
Figure 7.7.7 Panoramic radiograph, 15 months after treatment
initiation (postalveolar bone grafting).
treatment cannot achieve functional and/or acceptable
esthetic occlusion and facial harmony. Such surgery
should be timed to minimize any adverse effect on
• Many patients with clefts present with a much larger
transverse discrepancy than presented in this case.
Itwould be prudent to use other forms of expansion
such as a standard rapid palate expander (RPE) or
possible subsequent growth. Earlier surgery may be
indicated when there are serious concerns regarding
compromised airway, jaw function, speech, or psychosocial adjustment
Self‐Study Questions
1. Orthodontic treatment of the patient
withclefttypically occurs in multiple phases.
True/False
2. The timing of bone grafting of the
alveolar cleft is based solely on the patient’s age.
True/False
3. What type of graft is most commonly used for
cleft bone grafting?
4. What is the key factor in determining the timing
of orthognathic surgery in a patient with cleft?
Answers are located at the end of the case
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