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Pediatric Dental Health 

Orthodontic Management of Children with Cleft Lip & Palate

Why Orthodontics?
Surgical repair of the lip and palate invariably leads to a series of secondary growth disturbances.
These early surgeries tend to result in poor skeletal and dental growth in the transverse and antero-posterior planes, especially in the maxilla. 

Dealing With the Consequences of Cleft Lip and Palate Surgery
1. Lip repair may bring about a rapid transverse narrowing of the anterior arch. 
Following palate surgery, the tendency to crossbite may be increased when palatal scar tissue inhibits the widening of the maxillary arch.
2. Palatal scar tissue, especially that formed in the tuberosity areas, may restrain the normal downward and forward translation of the maxilla. 
In severe cases, and particularly with complete unilateral clefts, this leads to maxillary retrusion and a class III incisor relationship.
3. An increase in resting lower face height is commonly found, arising perhaps from secondary adaptations of mandibular position, and from the need for oral breathing when nasal airflow is diminished.

A Suggested Protocol for Treating Clefts
1. Optional pre-surgical orthodontics – in infancy
2. Surgical repair of lip and palate
3. Phase I orthodontics - in mixed dentition: differential expansion & alignment
4. Surgical bone graft in area of lateral incisor(s)
5. Phase II orthodontics – in permanent dentition: full mechanotherapy to align dentition
6. Orthognathic surgery ( + phase III orthodontics): integrated with growth completion
7. Prosthetic & esthetic reconstruction – young adults

Infant undergoing nasal alveolar molding for cleft palateIs Early Dentofacial Orthopedics Advisable?
•Given the already demanding program of basic treatment required for the cleft child, the inclusion of early orthopedics as a routine measure remains controversial.
•Cost-effectiveness analysis showed that the early orthopedic treatment was significantly more expensive than monitoring the cleft children with surgical intervention only. (Severens et al., 1998)
•New studies show: No difference in pre-adolescent growth by cephalometric linear measurements.
(Gerlein,E. A Cephalometric analysis of facial growth following presurgical orthopedics for unilateral and bilateral complete cleft lip and palate. Masters thesis, HSDM, 2002)
•No difference in pre-adolescent growth as compared to GOSLON standard.
(Chan, K. The effects of active presurgical orthopedics on dental arch relationships and facial growth in unilateral complete cleft lip and palate. Masters Thesis, HSDM, 2002)

The Role of Orthodontics - in Perspective
•"Most of the improvements in orthodontic treatment outcomes over the past 60 years are actually related to improvements in surgical techniques rather than any significant innovations in orthodontic appliances."
(Long, R E et al.Orthodontic Treatment of the Patient With Complete Clefts of Lip, Alveolus, and Palate: Lessons of the Past 60 Years. Cleft Palate–Craniofacial Journal, (November 2000) Vol. 37 No. 6, 533-547)

Introduction to Mixed Dentition Orthodontics
•Orthodontic dental records (x-rays, photos, and models) at 4-5 years of age in preparation for evaluation of teeth and cleft size.
Between the ages of 4 to 6 years, the premaxilla is usually ventroflexed and overlaps one or both lateral palatal segments, which may be in crossbite.
•A quad helix palatal expander with soldered anterior finger springs is cemented to the second deciduous molars.
•The premaxilla needs to be uprighted prior to correcting the posterior crossbite.
•As the premaxilla and lateral palatal segments are moved outward, the anterior cleft space is uncovered.
•A palatal retainer with an acrylic anterior extension to cover the anterior cleft space(s) is placed and kept in position until the alveolar cleft is bone grafted and all fistulas are surgically closed.
•In young children with unilateral clefts, a quadhelix usually achieves the desired change. 
•In bilateral clefts,bilateral symmetric expansion is sometimes needed and a traditional expansion screw (Hyrax appliance)is effective. One turn per week. 

The Role of the Alveolar Bone Graft
•In a dentition with missing lateral incisors in the cleft area, an autogenous bone graft is usually required before canine eruption. 
•With alveolar bone grafting, the bony defect is restored prior to the time of canine eruption.
•The grafted hip bone assumes all the characteristics of alveolar bone and permits spontaneous eruption of the canine and orthodontic tooth movement through the former cleft site.

The Role of Orthognathic Surgery
•The correction of severe maxillary retrusion is not within the scope of orthodontic treatment.
•The incidence of maxillary retrusion requiring end-stage orthognathic surgery is approximately 25%.
•Surgical emphasis is placed on advancing the maxilla rather than setting back the mandible.
•Development of the techniques for maxillary osteotomies promoted by Obwegeser (1966, 1969) and Bell (1973, 1975), and especially the surgical advancement of the cleft maxilla, further expanded orthodontic treatment capabilities.

The Role of Distraction Osteogenesis
•DO is a process of growing new bone by intentionally stretching preexisting bone tissue.
•DO can also be applied to patients with cleft lip and palate. 
•A well-known modality is surgically assisted maxillary expansion in adults that transversely distracts the hard palate through the midpalatal suture.

Oral Hygiene Instructions
•Parents should be shown how to lift the repaired lip, stretching the lip carefully by sliding an index finger along the labial gingiva.
•An interspace brush is especially helpful for teeth in the cleft region of the hard palate. Easy to make!
•Parents should be given the opportunity to practice the toothbrushing technique in the dental office.
•The parents need extra support, encouragement, and praise - to persevere.

Copyright ©2008 Daniel Ravel DDS, FAAPD

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