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Cleft Lip and Palate: Protocol for Orthodontics Treatment

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 Global Journal of Research in Dental Sciences
Volume 01| Issue 01 | July - Aug | 2021
Journal homepage: https://gjrpublication.com/journals/

Original Research Article

Cleft Lip and Palate: Protocol for Orthodontics Treatment
Abdulgani Azzaldeen1, Nezar Watted2, *Abu-Hussein Muhamad3
1
Istituto Stomatologico Toscano, University Guglielmo Marconi of ROME, Italy, Al-Quds University, School of
Dentistry, Jerusalem, Palestine
2
Center for Dentistry, Research and Aesthetics, Jatt /Israel.
3
Practice limited to Children's Dentistry, Aesthetics Dental Clinic ,Athens, Greece
*Corresponding author: DR. ABU-HUSSEIN MUHAMAD
Limited to Pediatric Dentistry DDS, MSc, MScD, Cert. Ped. Athens-Greece

Abstract
Cleft lip and palate represent one of the great challenges of craniofacial surgery, with initial descriptions of the
condition and surgical repair dating back to ancient times. Despite many diagnostic and technical aspects remaining
unqualified, much progress has been achieved in understanding and treating this deformity. From more complex
genetic studies clarifying its etiology to less mutilating surgical techniques, these advances have helped improve
prevention and appropriate care. A protocol for the treatment of cleft patients should followed by the healthcare
providers, and coordination amongst them is a major contributor to success in cleft treatment.

Keywords: Cleft patients, Treatment protocol and Teamwork management.

Copyright © 2021 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original
author and source are credited.

INTRODUCTION History
Cleft lip with or without cleft palate [CL(P)] is the The first recorded operative treatment of a cleft
most common congenital malformation in the head and patient has been attributed to the period of the Chin
neck. The birth of a child with a cleft is a difficult and (Tsin) Dynasty (c390 AD). The repair was of a cleft lip
emotionally charged time for the child's family. [1] only, and no mention of cleft palate repair was made.
Evaluation and treatment of the child with cleft lip Palatal clefts were confused with the more common
and/or cleft palate requires a long-term comprehensive fistulas resulting from tertiary syphilis and were not
and multidisciplinary approach in terms of medical, addressed surgically because of this association. [3]The
surgical, dental, and psychological intervention best greater technical challenges of cleft palate repair no
accomplished in conduction with a cleft palate team.[2] doubt presented a barrier to surgical treatment as well.
Although the first known cleft palate repair was
performed in the early 19th century, the introduction of
anesthesia permitted a quantum leap in treatment as it
did for many diseases.[4]John Stephenson (1797–1842),
a physician who was born with incomplete cleft palate,
wrote the earliest recorded description of palatoplasty.
As a medical student in Edinburgh, he traveled to Paris
to observe the renowned surgeon, Philibert Roux
(1780–1854). While he was there, Roux noted his
abnormal speech pattern; he performed the primary
repair of his velum when Stephenson was 22 years old.
In his thesis, Stephenson wrote in remarkable detail of
his speech quality: I always pronounced /th/ like /s/. As
I grew up, the adjacent parts tended to close the defect,
and by speaking slowly I articulated better. [5]Thanks to
Fig-1: Orofacial Clefts the nasal quality of the language, I used to speak French
more clearly than English. Nature is kind and trying to

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*Corresponding author email:
 Global J Res Dent Sci. 2021; 1(1), 21-32

correct her mistakes, did her best to improve my

unpleasant voice by contracting as strongly as possible
the muscles of the nasopharynx … I believe that the
nasal sound was due to faulty vibration of the air in its
passage from lungs to nares, because the fissure
prevented the soft palate from functioning. [5] Following
the description of his speech, [Fig.1] Stephenson wrote
in detail of the procedure, including the positioning
(seated upright in front of Dr Roux), anesthetic (none),
difficulties (breathing and bleeding), and postoperative
course (respiratory difficulty, nothing to eat or drink for
29 h, and discomfort of suture removal). He also
described the quality of the postoperative speech: It
must be confessed that some of the nasal quality is still
present. Old habit and the above-mentioned muscular
contraction were too much for me. The repaired Figure-2: Complete cleft of the secondary palate.
instrument is not yet fulfilling its proper duties to giving
the help it should to my vocal faculty. Who can deny
the all-importance of habit? The same problem often the technique of palatoplasty but also advanced
occurs today when cleft palate repair is delayed until techniques of local flap closure and transplantation.
later in life.[6] After the acceptance of his doctoral Dieffenbach’s possibly most important contribution to
thesis, Stephenson returned to his home in Canada and plastic surgery was the introduction of ether anesthesia
eventually became a principal founder of McGill to plastic surgical procedures.9 Dieffenbach had been
Medical College, where he served as Professor of introduced to anesthetic technique during a
Anatomy, Physiology, and Surgery.[6]Roux later demonstration at Massachusetts General Hospital in
published his account of the procedure in 1825, 1846 and began applying it to routine surgical
describing the simple suture closure of the surgically procedures before his death in 1847. [6] He was so
freshened edges, which he termed “staphyloraphie”. revered in Germany that he received an official state
burial. After the death of Dieffenbach, Bernhard von
Johann Friedrich Dieffenbach (1792–1847) studied Langenbeck (1810–1887) succeeded to the position at
under von Graefe at the University of Berlin. [10] the University of Berlin. Incorporating his extensive
Dieffenbach expanded the technique of soft palate work with bone and periosteum of the extremities
repair to include closure of the hard palate. during the Franco-Prussian war, he was the first to
Dieffenbach’s palatoplasty method involved bringing describe the mucoperiosteal plane of dissection and to
together the cleft bony segments by a series of twisting use its advantage in mobility to cleft palate closure. [12]
silver or lead sutures passed through punch holes in the His technique, with various modifications, is still
bony palate.[11] He eventually designed and advocated widely used today. The combination of Dieffenbach’s
lateral mucosal relaxing incisions to aid successful soft introduction of general anesthesia and von
tissue closure. Later, following von Graefe at Charité Langenbeck’s use of mucoperiosteal flaps ushered in
Hospital in Berlin in 1840, he not only improved the modern era of cleft palate surgery. The ensuing
century has brought greater understanding of the
anatomy of the cleft palate, as well as improved surgical
approaches.[2] Dorrance’s introduction of a pushback
[Fig.2] technique, Veau’s dissection of the levator
muscles, and the more recent techniques introduced by
Bardach and Furlow are particularly significant. As
many of the operations are still in use, we review them
in the appropriate technical areas of the chapter rather
than in this historical overview.[1]

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 Global J Res Dent Sci. 2021; 1(1), 21-32

Figure-3: The ENT treatament of Cleft Lip and Palate

Incidence and Genetics syndromic clefts may be single gene transmission

Cleft lip and cleft palate are common congenital (mendelian inheritance: autosomal dominant, autosomal
malformations, second only to clubfoot (talipes recessive, or X-linked), chromosomal aberrations
equinovarus) in frequency of occurrence. Cleft lip with (trisomy, deletion, addition, or translocation). [2] Other
or without cleft palate appears to be genetically distinct causes can result in clefting, with a recognizable
from isolated cleft palate without cleft lip. [2]The former syndrome, such as teratogens (ethanol, thalidomide,
occurs in about 1 of 1,000 newborns (considering all phenytoin), and environmental factors (amniotic band
racial groups), the latter in about 1 of 2,000. The syndrome, maternal diabetes mellitus, maternal dietary
incidence of CL(P) varies by ethnic group, with the folate [Fig.4]deficiency , ethanol, or tobacco smoke
highest frequency occurring in Native Americans, about exposures).[15] Estimates of the percentage of syndromic
3.6 of 1,000 births [1], followed by Asians with 2.1 of causes in the cleft population have ranged from as high
1,000 births, whites with 1 of 1,000, and blacks with as 60% to as low as 15%. More than 200 recognized
0.41 of 1,000 births .[2] Conversely, the incidence of CP syndromes are known to include a facial cleft as a
is constant among ethnic groups (0.5 of 1,000) manifestation .[1,2,16,17] A thorough head and neck
.[13]Gender differences (male:female ratio) are noted to examination and search for any other structural
be about 2:1 for CL(P) and 1:2 for CP. Overall, the anomalies, such as synostosis, telecanthus, maxillary or
prevalence of cleft types in the population is as follows: malar hypoplasia, abnormal pinnae or atresia, facial
complete clefts of the lip, alveolus, and palate, about nerve paresis or paralysis, abnormal mandibular shape,
45%; cleft lip, alveolus, or both, about 25%; and CP, and excursion or malocclusion, must occur to identify
about 30%.[14] [Fig.3] the presence of a syndrome. [1,8]Identification of a
syndrome, especially one with a known inheritance
Both CL(P) and CP can be further subcategorized as mode, has important prognostic implications and is
syndromic or nonsyndromic. Syndromic clefts are those important to the family in terms of genetic
that are part of, or associated with, a recognized pattern counseling.[15, 18] [Fig.4]
of human malformation or syndrome. [1] The cause of

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 Global J Res Dent Sci. 2021; 1(1), 21-32

Figure-4: Chromosome structure.

Embryologic Considerations and Classification The first phase involves proliferation of the
Normal embryologic development of the lip and mesoderm and ectoderm in the frontonasal process. The
palate can be considered to occur in two related phases: frontonasal process has three components: (a) an
the first phase (beginning at 4 to 5 weeks' gestation), anterior labial component, which forms the philtrum;
involving the development of the upper lip, nose, and (b) an anterior palatal component forming the alveolar
primary palate or premaxilla (the portion of the bony part of the premaxilla (with the central and lateral upper
palate anterior to the incisive foramen containing the incisors); and (c) a posterior palatal component forming
four upper incisors), and the second phase (beginning at the portion of the hard palate anterior to the incisive
8 to 9 weeks' gestation), involving the development of foramen. Laterally, proliferation of mesoderm with
the secondary palate (the hard and soft palate posterior overlying ectoderm occurs in the maxillary processes
to the incisive foramen).[14,16,17,18] that eventually form the lateral lip segments and nasal
alae.[1,2,13,14,16,18]

Figure –5: The age treatment of Cleft Lip and Palate

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 Global J Res Dent Sci. 2021; 1(1), 21-32

Embryonic formation of the frontonasal process begins septum).[18] A complete cleft palate refers to a cleft of
with differentiation of the olfactory placode epithelium both the primary and secondary palates and is nearly
.[2] Morphogenetic movement of the placode and always associated with a cleft lip. [18,19] The term
differential growth forms the characteristic curl of the incomplete cleft palate is synonymous with a cleft of
placode into the nasal alae.[1] The most recent theory of the secondary palate or can be used to describe a palatal
palatal formation involves contact, with subsequent cleft with an area of intact mucosa.[20] The classic
resorption of the contacting surface epithelial cells and submucous cleft palate (bifid uvula, midline diastasis of
adhesion of the contacting prominence. It is believed the levator muscles, and posterior hard palate notching
that this occurs in both primary and secondary palate caused by loss of the posterior nasal spine) is accurately
formation (i.e., contact, loss of surface epithelial cells, a microform expression of a cleft of the secondary
and mesodermal contact, with fusion and penetration palate.[21,22,23]
across the junction).[18] Differences in the gestational
time of development and fusion of the primary palate General Team Management Approach
(about 30 days) and secondary palate (about 50 days) Because the problems that confront affected children
are reflected in the separate genetic inheritance and their parents are complex, variable, and long-term,
patterns.[1, 2, 18] the facial surgeon should be allied with a cleft palate or
craniofacial team that meets regularly.[1,2][ Fig.5]This
Clefts of the lip are either unilateral right or left, or allows valuable consultation with colleagues in
bilateral (group I).[13-16] They can be complete (with pediatrics, plastic surgery, dentistry, orthodontics,
extension into the nasal floor) or incomplete (extending speech pathology, and audiology on a regular basis.
from a slight muscle diastasis at the vermilion to a small Other experts (e.g., neurosurgery, ophthalmology, and
bridge of tissue at the nasal sill). [13] A cleft involving prosthodontics clinicians) can be consulted, as needed,
only the lip can occur as an isolated entity, but a cleft of as well as oral surgeons, geneticists, nurses, and social
the alveolus is always associated with a cleft of the workers.[24] The team approach functions best in an
lip.[14,17,18] Following the birth of a child with a cleft, the parents
often react with disappointment and anger, followed by
Group III includes children with a cleft lip and depression, then guilt. Initial counseling is important
palate. Clefts of the palate can be divided into primary and should be scheduled as soon as possible with a
(involvement anterior to the incisive foramen, group healthcare professional skilled in counseling parents of
IV) or secondary (involvement posterior to the incisive children with craniofacial anomalies. [26] Care and
foramen, group II).[17,18] Palatal clefts also can be feeding in the first months of life should be
unilateral (the palatal process of one side is fused with demonstrated, and a general outline for the child's long-
the septum, resulting in communication of the oral and term care should be offered.[27,28] [Fig.6]
nasal cavities on one side only) or bilateral (no
connection between either palatal process and the

Figure-6: Professional Roles within a Cleft Palate or Craniofacial Anomaly Team

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 Global J Res Dent Sci. 2021; 1(1), 21-32

Anatomic Deformity of Cleft Lip and Palate Bilateral Cleft Lip

The anatomic deformity associated with CL(P) involves In the bilateral complete cleft lip and palate, the
the soft tissues of the lip and nose, the cartilaginous and anatomy of the two lateral lip segments is similar to the
bony supporting structures of the nose and palate, and unilateral cleft lip.[32] The nasal deformity in the
the underlying bony maxilla.[29,30] [Fig.7] bilateral cleft lip often involves a very short columella
length, as well as widely flared alae with rotated and
displaced lower lateral cartilages.[33] The premaxilla is
often protruded with respect to the lateral maxillary
segments, which are often hypoplastic and displaced
posteriorly. [34]The prolabium (the central portion of the
lip) is positioned anterior to the premaxilla and
frequently is attached to the anterior gingiva of the
premaxilla.[35] The orbicularis oris muscle fibers insert
into the lateral cleft margins at the nasal base and alae
region, but are rarely found in the prolabium (except in
incomplete clefts).[33-35]

Cleft Palate
The deficiencies associated with cleft palate depend
on the location of the defect in the palate. In the normal
palate, the tensor veli palatini and levator palatini
muscles within the soft palate insert into an aponeurosis
at the midline raphe.[14,36] In the cleft palate, the muscle
fibers follow the medial margin of the cleft and insert
into the medial cleft edges and the posterior edge of the
lateral bony hard palate. Clefts involving the alveolus
Figure -7: Nasoalveolar molding (NAM) appliance. can disrupt normal dental development, eruption, and
Hard plate facilitates nipple compression. retention.[37,38]

Unilateral Cleft Lip Facial Growth

Although the degree of deformity depends on the The subject of normal human facial growth is
severity of the cleft, the orbicularis oris muscle, blood extremely complex and incompletely understood; and
supply, and innervation generally follows the external superimposing a cleft defect complicates an already
form or silhouette of the cleft lip.[1,2] For the incomplete complex process. Many children with clefts will
cleft lip, the muscle fibers of the orbicularis oris are develop collapse of the alveolar arches, midface
often intact but decreased and hypoplastic across the retrusion, and resultant malocclusion as they approach
width of the cleft. In the complete cleft lip, the muscle their teenage years.[2,39] The underlying cleft deformity
fibers are directed superiorly following the cleft itself, as well as the surgical procedures performed to
margins and terminate at the columella base medially correct the defect, have been implicated as possible
and beneath the nasal ala laterally. [13,15]Often increased contributing causes of these developments.[40]
muscle bulk exists in the lateral segment, whereas Currently, controversy exists regarding the relationship
muscle is deficient in the medial segment. The between surgical procedures and maxillary growth in
vermilion tends to be thinner on the medial side, which terms of the sequencing of surgical procedures, the
is an important fact to note during the definitive lip timing of the cleft repair, whether or not the cleft lip
repair.[15,31] repair itself has an effect on maxillofacial growth, and
the various surgical techniques of lip and palate
The nasal deformity associated with the unilateral repair[1,39]. Of interest, it is common in nonsyndromic
cleft lip involves the nasal ala, alar base, columella, older children whose cleft is unrepaired to have
medial and lateral crura of the lower lateral cartilage, relatively normal midfacial projection and occlusion
dome, and septum, as well as the underlying maxilla. (personal observation).[1,2,39,40]
Because the lateral maxillary segment is often displaced
inferiorly, the alar base and lateral crus are displaced
Orthodontics in cleft lip and palate
laterally and inferiorly. As a result, the dome is
flattened and rotated downward on the cleft side; the
management
The state of the art for the management of patients
columella is short, causing a horizontal orientation to
with oral facial clefts requires the use of a
the nostril on the cleft side.[30,31]
multidisciplinary approach as various structures,
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 Global J Res Dent Sci. 2021; 1(1), 21-32

traditionally treated by several specialists, are involved. and/or osseointegrated implants. It is our experience
In the oral cavity, the cleft affects not only the soft and that patients treated within the context of the
hard palate, but also the alveolus and dentition. [30,41] The multidisciplinary approach can obtain excellent
structural rehabilitation of these patients requires the outcomes related to speech, ideal occlusion, satisfactory
surgical correction of the soft- and hard-tissue defects lip aesthetics, and skeletal balance . [43]However, it is
as well asthe secondary effects of the cleft on maxillary the secondary cleft nasal deformity that still gives the
development, dental support, and dental–occlusal patient the “cleft stigmata.” [30,42] In recent years, new
alignment.[1,2,13,15] [Fig.8] The role of the orthodontist in orthodontic and surgical treatment modalities have
cleft management is essential as the orthodontist assists become available that may further improve outcomes in
the surgeon during all stages of reconstructive care: in patients with orofacial clefts. In infancy, this includes
the early stages, with presurgical nasal and maxillary the use of presurgical nasoalveolar molding techniques.
orthopedics; during the transitional dentition stage, with In the mixed dentition, novel orthodontic–orthopedic
alignment of the maxillary segments and dentition in approaches to correct maxillary hypoplasia are utilized;
preparation for secondary alveolar bone grafting; and and, in the permanent dentition, the use of new
during the permanent dentition and late adolescent appliances and dental materials to facilitate orthodontic
years, by obtaining satisfactory dental and occlusal treatment and the application of bone anchorage screws
relationships and also to prepare the dentition for (BAS) to facilitate orthodontic tooth movement are
prosthetic rehabilitation and orthognathic surgery, if employed.[43] In addition, the use of distraction
required. In addition, it has been the role of the osteogenesis to improve the position of the maxilla in
orthodontist to monitor craniofacial growth and dental those cases with severe maxillary hypoplasia has
development, as well as the treatment effects on these become a well-accepted procedures.[44] Finally the
patients through the use of roentgencephalometry. [18] availability of new diagnostic techniques such as digital
With this approach, the management of the cleft patient skull and dental models, three-dimensional (3D)
has evolved dramatically in recent years. [29,30,42]The photogrammetry, lower radiation computed tomography
reason for improved outcomes is based on refinements (CT) scans, cone beam CT (CBCT), and the
in primary and finishing surgical techniques, as well as development of 3D digital protocols to plan
timing and incorporation of other procedures such as orthognathic surgery are now at the forefront of current
presurgical orthopedics, orthodontics, and new orthodontic
prosthetic approaches utilizing resin-bonded prosthesis

Figure-8: Pre-treatment (a) panoramic

and surgical approaches. The efforts towards Orthodontic treatment can be continued 8–12 weeks
improvement of orthodontic and surgical treatment after bone graft surgery. As soon as appropriate
strategies developed for noncleft patients will benefit maxillary arch and dental relations are achieved, the
orthodontic appliances are removed and the patient is
the challenging problems presented by cleft patients and
placed in retention until there is full permanent
are a welcome addition to the current treatment dentition. [1,2]Teeth that were severely rotated prior to
protocols.[28,30,45] [Fig.8] treatment need to be retained. [13]Absent teeth can be
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 Global J Res Dent Sci. 2021; 1(1), 21-32

temporarily replaced with a removable prosthetic achievable goal to eliminate the need for artificial
appliance to improve aesthetics and limit the effects on replacement teeth .[1,2] In these cases in which space
speech production. [46] Patients treated with the protocol closure is not possible, the use of adhesive
outlined above complete the preparatory phase of bridgeworksor of implants in the grafted alveolar ridge
orthodontic treatment in the preteen or early teen years. has become a treatment of choice. A further possibility
Patients are followed every 6 months to determine their is the transplantation of a lower premolar to the upper
craniofacial growth and dental development, especially arch. [13-16] [Fig.12]
eruption of the maxillary lateral incisor and canine on
the cleft side. [15]Occasionally, the maxillary canine is The development of effective orthognathic surgical
impacted and requires surgical exposure and techniques in the 1970s and 1980s has provided
orthodontic incorporation into the arch as the child is in orthodontics with the means to complete treatment of
the full permanent dentition.[47] Impacted or severely almost all cleft patients.[1,2] The use of three-
malpositioned cleft-side maxillary lateral incisors are dimensional cephalometry, computed tomography, and
usually extracted .[47,48] scanned dental models, video imaging, and computer-
generated images have all contributed to the
Patients with CLP usually require an extensive and improvement of orthognathic surgery planning. [25-
30]
prolonged orthodontic treatment parallel to the surgical Although initially developed for non-cleft
treatment. Orthodontic treatment may be required: (a) in orthognathic surgery, the use of these applications in
infancy, before initial surgical repair of the lip, (b) cleft patients has been increased rapidly.[1,2,27,29,30]
during the primary dentition period, (b) during the
mixed dentition period, (c) during the permanent Finally, if it is determined that there is
dentition period and (d) in the late teens after anteroposterior skeletal disharmony, the reconstructive
completion of facial growth, in conjunction with team has to decide if it is convenient to do the bone
orthognathic surgery.[1,2,13,15] [Fig.9] grafting in the transitional dentition or if it should be
done in combination with future orthognathic surgical
The introduction of passive realignment of the hard procedures.[1,2] Patients in whom there is marked tissue
palate shelves has been introduced by McNeil and later deficiency, including maxillary hypoplasia and
by Burston[26,27]. This orthopedic approach makes CLP congenitally missing teeth, are likely candidates for
repair easier and may improve the aesthetic outcome of postponement of the traditional approach for secondary
primary CL nasal repair by repositioning the alar alveolar bone grafting and will be treated later on in the
base.[28] However, unless the appliances used are permanent dentition in combination with orthognathic
continued throughout the period of facial growth, their surgery.[13-16] If it is deemed important to preserve the
long-term influence on facial growth and dentition dentition adjacent to the alveolar cleft, orthodontics are
remains still a matter of discussion.[29,30] therefore indicated, even in the presence of a skeletal
disharmony[49]. The purpose of the orthodontic
Orthodontic intervention in the primary dentition treatment is then to prepare the dentition for the alveolar
has been recommended over the past 60 years, although bone graft and also to coordinate the maxillary arch to
less in recent years.[30]Suggested treatment at that time the mandibular arch for future orthognathic surgery that
ranged from full bandingto routine arch will be performed in the teen years. This approach
expansion[1`,2,29,30] [Fig.10] minimizes the required orthodontic treatment prior to
orthognathic surgery in the adolescent years.[47,50]
Numerous authors have described the beneficial [Fig.13]
effects on dental and skeletal growth development of
cleft patients through the elimination of functional and
structural problems at this developmental stage.
[1,2,16]
The most common procedures for this purpose
include: (a) maxillary expansion to correct the reduced
transverse dimension, (b) incisor alignment and
proclination to remove crowding, rotations, and anterior
crossbites, as well as (c) maxillary protraction to reduce
maxillary retrusion.[28-30] [Fig.11]

Many authors report an increasing frequency of

permanent dentition treatment, which is possible using
the common orthodontics approaches as for non-cleft
patients. [25]Since the routine use of bone grafting, space
closure in the cleft site has become a desirable and Figure-9: Rapid maxillar expander in place.
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 Global J Res Dent Sci. 2021; 1(1), 21-32

Orthodontic management following the growth patterns than those seen in noncleft
developmental approach outlined previously allows the individuals.[2]
clinician to take advantage of developmental and
growth changes and permits the patient and family to However, cleft patients have significant growth
recognize the need for distinct phases of orthodontic potential. If this potential is not negatively affected by
treatment which also allow for sufficient rest space the reconstructive procedures required by the patient, it
between stages[47]. This approach assures patient and is likely that a favorable outcome will be obtained.
[1]
family acceptance, compliance, and cooperation with Orthodontic treatment will be simplified if minimal
the treatment protocol.[1,2] growth disturbances affect the patient. [2]Simplification
and shortening of orthodontic treatment, which is
Since the orthodontist participates in the care of a usually the longest therapeutic intervention for many
cleft child from infancy into adulthood, it is imperative cleft patients, are desired as this will decrease the
to recognize that abnormal facial growth will present an burden of care (e.g., patient, family, provider, public
added challenge to the reconstructive team.[48] It is health system, society). [25,26] Cleft teams
understood that cleft patients do have different facial

Figure-10: (a) Occlusal pre-treatment and (b) with the hyrax appliance in place

Figure -11: A. Periapical x-rays before

should strive to obtain optimal outcomes by critically that minimize scarring in the anterior maxilla (i.e.,
assessing their protocols and incorporating proven delaying alveolar bone grafting and minimizing palatal
strategies to manage their patients.[14] It is accepted that scarring by avoiding damage to the maxillary body).
surgery will likely create significant scarring in the This, in turn, will result in less need for extended and
infant maxilla, resulting in growth attenuation. complex orthodontic procedures.[27,47]
[26]
Careful attention should be given to those protocols

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 Global J Res Dent Sci. 2021; 1(1), 21-32

Figure-12; Comparison (a) pre- and (b) post-treatment upper arch

Figure -13: Final radiographs with brackets in place.

The important contribution of the orthodontist to the palate team approach best provides long-term
comprehensive surgical orthodontic management of the multidisciplinary management.;
cleft patient is illustrated. The role of the orthodontist is • Cleft lip and palate occurs in 1 of 1,000 births;
to support the surgeon with all aspects of craniofacial cleft palate alone occurs in 1 of 2,000 births.
growth, dental development, occlusion, and treatment Clefts occur in children with recognizable
planning, so ideal outcomes can be obtained. [25] With syndromes or as an isolated deformity
the addition of nasal alveolar molding as well as (nonsyndromic)
maxillary distraction osteogenesis, the traditional • Complex genetic and environmental
protocols for cleft management have been interactions are present in most nonsyndromic
expanded[Fig.13]. In addition, the incorporation of new clefts.
technological advancements in orthodontics, such as • Lip and palate embryologic development
highly flexible orthodontic arch wires, self-ligating occurs in two phases: the first beginning at 4 to
orthodontic appliances, BAS, and accessibility to new 5 weeks (lip, nose, premaxilla) and the second
3D imaging technology, facilitates the required beginning at 8 to 9 weeks (secondary palate).
treatment interventions.[47-50] It is hoped that these • The relative prevalence of cleft types include
innovations will provide clinicians with new strategies complete cleft lip, alveolus, and palate, 45%;
for the difficult management of the cleft patient, and cleft lip with or without cleft alveolus, 25%;
will provide the patient with outstanding outcomes. and clefts of the secondary palate only, 30%.
[,25,47]
The treatment plan of the patient should be • Critical psychosocial and nutritional issues
developed around the anatomical, functional, and should be addressed in the neonatal period or
developmental needs of the patient. Close cooperation even prenatally.
between the surgeon and orthodontist is imperative for a • The infant is discharged home from the
successful outcome.[1,2,13,15,25.47] newborn nursery only after a satisfactory
feeding method has been established and the
SUMMARY parents are capable and comfortable caring for
Cleft lip and palate are the most common congenital the infant.
malformations involving the head and neck, and a cleft
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 Global J Res Dent Sci. 2021; 1(1), 21-32

• Lip taping or lip adhesion, an early preliminary 11. Goldwyn RM. (1968);Johann Friedrich
option for cleft lip, can be performed at 2 to 4 Dieffenbach (1794– 1847). Plast Reconstr
weeks of age. Definitive lip repair is then Surg.;42:19–28.
performed at 4 to 6 months of age. Lip 12. Goldwyn RM. Bernhard von
adhesion, which can influence scar formation, Langenbeck.(1969); His life and legacy. Plast
is used in carefully selected cases. Reconstr Surg. 44:248–254.
• The rule of tens is used to determine suitable 13. Abu-Hussein M (2012) Cleft Lip and Palate –
age for lip repair: the infant is at least 10 weeks Etiological Factors. Dent. Med. Probl 49(2):
old, weighs about 10 pounds, and has a 149-156.
hemoglobin of 10 g. 14. Abu-Hussein Muhamad, Abdulgani
• Cleft palate repair is usually performed at 8 to Azzaldeen, Watted Nezar, Kassem Firas
12 months of age as long as the child is (2014) The Multifactorial Factors Influencing
gaining weight and growing in a normal Cleft Lip-Literature Review. International
fashion. Journal of Clinical Medicine Research 1(3):
• Patients with cleft lip and palate require a team 90-96.
approach for their treatment, comprised of 15. Muhamad AH, Azzaldeen A (2012) Genetic of
several specialists. This multidisciplinary care Nonsyndromic Cleft Lip and Palate, 2012.
starts from birth and continues into adulthood, 1:510.doi:10.4172/ scientificreports.510
and coordination amongst specialists is a major 16. Muhamad Abu-Hussein, Nezar Watted,
contributor to success in cleft treatment. Viktória Hegedűs, Péter Borbély Abdulgani
Azzaldeen (2015) Human Genetic Factors in
Non-Syndromic Cleft Lip and Palate: An
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