Phẫu Thuật Tạo Hình (Tập 3): Sọ Mặt, Đầu Cổ Và Nhi Khoa – Neligan (Ấn bản 4)

590
SECTION I
CHAPTER 24 • Alveolar clefts
institutions will be required to determine if these results can
be reproduced.
Primary bone grafting
On self-evaluation of this approach on 20 consecutive patients,
Rosenstein et al.24 reported no cephalometric evidence of
impaired growth compared to a similar cohort who did not
undergo primary grafting. Hathaway et al., at a separate
center, retrospectively evaluated 17 patients who underwent
primary grafting, and reported no difference in arch form
compared to ungrafted clefts.39 Ross evaluated cephalograms
from 15 cleft centers and reported that grafting in infancy may
have a negative effect on both vertical and horizontal midface
growth, but it was not clear whether this was any greater than
the effect of secondary bone grafting between the ages of 4
and 10 years.40 The potential increased risk of exposing infants
to an additional surgery and anesthesia in the first year of life
must be weighed against the possible benefit of avoiding a
secondary bone graft procedure in mixed dentition.41
Secondary bone grafting
Some of the most commonly used outcome measures for bone
grafts are: the Bergland scale,18 based on interdental height of
bone; the bone height index,42 based on the percentage of bone
covering the roots of adjacent teeth; the Chelsea index,43
measuring position and quality of bone; and the Kindelan
bone-fill index,44 which is a four-point scale of percentage
bone infill. All but the last require eruption of the permanent
cuspid before they can be used. In addition to the variability
of outcome measures, there is wide variation in the literature
in timing of evaluation, as well as limitations inherent to plain
film analysis such as rotation variability. Some have proposed
cone beam computed tomography as a superior method of
graft evaluation.45,46
In the context of these study limitations, the success rate of
secondary alveolar bone grafting in the literature ranges from
70% to 80% in most studies,42,43,47,48 to over 90% in a few
reports.49–52 Scottish cleft services reported a dramatic increase
in graft success from 58%53 to 76%54 as a presumed result of
a reorganization that decreased the number of surgeons
Grayson et al.34 described the use of nasoalveolar molding
(NAM) instead of the Latham device to narrow the cleft prior
to GPP, with the theory that the more passive “guided
molding” of NAM would be less detrimental on future facial
growth and dental relationship. In retrospectively examining
their cohort at mixed dentition, they reported bone formation
in 80% of clefts with 73% not requiring secondary bone graft­
ing.35,36 In evaluating facial growth, they found no adverse
effect on midface growth during mixed dentition, and on
repeat analysis up to 18 years of age.37,38 Continued prospec­
tive evaluation of the NAM and GPP protocol at other
Fig. 24.11  Panorex radiograph of the bilateral transport distraction performed on
the patient shown in Figs. 24.4 and 24.10. (A) On the left side, the patient had
undergone a previous extraction, creating an ideal site for the interdental osteotomy.
On the right side, the osteotomy is distal to the third tooth on the segment.
(B) Post-activation, the canines are now adjacent to the central incisors and the
alveolar clefts have been compressed. The distracted osteotomy contains generate
tissue that will ossify during consolidation, effectively lengthening the maxillary
arch.
A
B
Fig. 24.12  The same patient shown in Fig. 24.5 undergoing vertical alveolar transport distraction. See text for details. (A) Since the vertical height of alveolus below the
maxillary sinus was less than 10 mm, the site was augmented with an onlay autogenous split calvarial bone graft held in place with lag screws. (B) Three months later the
lag screws are removed and a rectangular osteotomy is created within the consolidated graft. An internal vertical distractor has been placed across the osteotomy with a
vector that will augment the vertical height of the alveolus and simultaneously lower the level of the gingival surface. (C) Radiograph of the device post-activation
demonstrating alignment of the transport segment with the adjacent gum line. The generated tissue within the superior osteotomy site will consolidate over 2 months.
A
B
C

591
Outcomes, prognosis, and complications
Although rhBMP2 shows promise in reducing healthcare
costs and donor site morbidity, cognizance of reported com­
plications of rhBMP2, including ectopic bone formation, bone
resorption or remodeling at the graft site, hematoma, neck
swelling, painful seromas, and severe gingival swelling,
which led to the premature closure of one randomized clinical
trial,61 is paramount. Additional theoretical concerns include
carcinogenicity and teratogenic effects.62 The risk–benefit
profile of rhBMP2 in cleft patients will likely remain unknown
for the next decade, pending results of additional high-quality
randomized controlled trials. Patient selection should, there­
fore, be based on enrollment in an institutional review board
(IRB)-approved trial with appropriate consent and evalua­
tion, including oversight by an independent data safety
monitoring board.
Late bone grafting
When an alveolar cleft is bone-grafted before eruption of the
cuspid, there is more than 80% chance of success, and the
result provides adequate long-term periodontal support. With
age, this success rate drops sharply, approaching 50% at 25
years of age.25,63 Grafting after eruption of permanent denti­
tion also does not correct periodontal defects (i.e., inadequate
periodontal ligament), even with subsequent orthodontic
movement into the graft.
The goal of grafting in adults is therefore no longer to
provide support for erupted teeth, but rather to provide suf­
ficient bone stock for prosthetic placement. In addition, the
adult alveolar cleft is typically larger due to the poor health
and loss of adjacent teeth. The technique of grafting an adult
cleft involves rigid fixation of a corticocancellous graft with
either resorbable or titanium fixation. Due to the slower
incorporation of this graft architecture, an increased attention
to the vascularity of the mucoperiosteal flaps and the nasal
closure is essential. The cleft is also minimized by segmental
maxillary osteotomies and advancement of the posterior
segment into the cleft. In bilateral clefts, staging the surgery
may be necessary. Implant placement should take place 3–4
months post-grafting to avoid loss of the graft.
Graft site augmentation
As with all bone, the alveolar graft requires mechanical stimu­
lation to avoid resorption. Eruption of teeth into the graft and
orthodontic movement of teeth can both provide this stimula­
tion. In some cases where canine substitution is not performed,
the bone graft placed to support the erupting canine may
experience an “unstimulated” region adjacent to the central
incision due to the missing lateral incisor. In these cases, focal
crestal resorption can occur and an alveolar augmentation
procedure is required prior to implant placement at skeletal
maturity.
performing bone grafts and the establishment of nationally
followed standard protocols.
Bone morphogenetic protein-2
Although a number of retrospective studies have shown
promising results comparing rhBMP2 in combination with
various non-autologous bone scaffolds to autologous iliac
crest bone grafting for isolated alveolar cleft repair,55–57 only
four prospective randomized trials have been reported.58–61
The first randomized trial of 21 skeletally mature patients
with a unilateral cleft alveolar defect showed that patients
treated with a collagen sponge soaked in rhBMP2 demon­
strated improved bone healing, and reduced donor morbidity
and cost compared to those filled with autogenous iliac crest
cancellous graft.58 This group did not trial rhBMP2 in growing
patients in mixed dentition due to their previous animal
studies that demonstrated ectopic bone formation in 1%, as
well as the high success rate of conventional autogenous
grafting in this age group.
The second randomized trial compared rhBMP2 collagen
matrices and iliac crest bone grafting in 16 patients aged 8–12
years with unilateral clefts.59 This study demonstrated signifi­
cantly lesser bone height in the BMP group at 1 year follow-up
as determined by computed tomography (CT) analysis. Bone
filling was equivalent, as was tooth eruption. There was a
greater incidence of significant swelling (37.5%) in the BMP
group, and 87.5% of patients in the iliac crest group reported
postoperative pain. Lengths of stay and surgical costs were
not reported in this study.
A more recent follow-up study including patients aged
8–15 years by this center compared three groups (rhBMP2
collagen matrices; iliac crest bone grafting; and GPP) of six
patients each.60 This trial demonstrated equivalency between
rhBMP2 and iliac crest bone grafting in terms of bone volume,
bone formation, maxillary height, and formed bone density at
12 months as evidenced by CT analysis. Complications,
lengths of stay, and surgical costs were not reported.
A fourth randomized trial from Sweden compared rhBMP2
hydrogel to iliac crest bone grafts in 8–11-year-old unilateral
cleft patients.61 In a total of four patients in the rhBMP2 arm,
the authors found that an rhBMP2 concentration of 50 µg/mL
failed to form bone, while patients receiving hydrogels with
an rhBMP2 concentration of 250 µg/mL experienced severe
postoperative gingival swelling, leading to premature trial
closure. Surgical times and hospital stays were lower in the
rhBMP2 group, but not significantly so.
Of note, only the first randomized trial58 was available for
evaluation in a recent Cochrane review.22 This first study met
inclusion criteria and was evaluated as a legitimate random­
ized controlled trial. It remains unclear if the remaining three
trials would meet stringent Cochran Collaboration criteria.
1. Brauer RO, Cronin TD, Reaves EL. Early maxillary orthopedics,
orthodontia and alveolar bone grafting in complete clefts of
the palate. Plast Reconstr Surg Transplant Bull. 1962;29:
625–641.
2. Georgiade NC, Pickrell KL, Quinn GW. Varying concepts in bone
grafting of alveolar palatal defects. Cleft Palate J. 1964;16:43–51.
3. Pickrell K, Quinn G, Massengill R. Primary bone grafting of the
maxilla in clefts of the lip and palate: a four year study. Plast
Reconstr Surg. 1968;41:438–443.
4. Schmid E. Die Annaherung der kieferstempfebei lippen-kiefer.
Gaumensplaten: ihre schadlichen folgen und vermiedung. Forschr
Keifer Geisichtschir. 1955;1:168–180.
Access the complete reference list online at

592
SECTION I
CHAPTER 24 • Alveolar clefts
5. Schrudde J, Stellmach R. [Primary osteoplasty of defects of the
inferior maxillary arch in cleft palate and harelip in infants;
preliminary report.]. Zentralbl Chir. 1958;83:849–859.
6. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar
and palatal clefts. J Oral Surg. 1972;30:87–92. Landmark article largely
recognized as initiating the popularity of secondary bone grafting. Boyne
introduced the concept in the 1960s, advocating treatment towards the end
of the first decade of life to minimize growth impairment while still
supporting eruption of the adult dentition. Most of the described
principles are still followed today.
12. Cassolato SF, Ross B, Daskalogiannakis J, et al. Treatment of dental
anomalies in children with complete unilateral cleft lip and palate
at SickKids Hospital, Toronto. Cleft Palate Craniofac J. 2009;46:166–
172. Retrospective study of 116 children with complete unilateral cleft
lip and palate treated since birth. The article quantifies dental anomalies
in permanent dentition associated with complete unilateral cleft lip
and palate and surveys treatment modalities used to address these
problems.
22. Guo J, Zhang Q, Wu G, et al. Secondary bone grafting for alveolar
cleft in children with cleft lip or cleft lip and palate. Cochrane
Database Syst Rev. 2011;(6):CD008050.
23. Liou EJ, Chen PK, Huang CS, et al. Interdental distraction
osteogenesis and rapid orthodontic tooth movement: a novel
approach to approximate a wide alveolar cleft or bony defect. Plast
Reconstr Surg. 2000;105:1262–1272. Detailed case-based review of
interdental transport distraction osteogenesis to treat wide alveolar clefts
by the recognized expert.
36. Sato Y, Grayson BH, Garfinkle JS, et al. Success rate of
gingivoperiosteoplasty with and without secondary bone grafts
compared with secondary alveolar bone grafts alone. Plast Reconstr
Surg. 2008;121:1356–1367, discussion 1368–1369. Most recent
retrospective evaluation by the New York University team of GPP
outcomes with and without secondary bone grafting. They concluded that
GPP alone or combined with secondary alveolar bone grafting results in
superior bone levels when compared with conventional secondary alveolar
bone grafting alone.
54. McIntyre GT, Devlin MF. Secondary alveolar bone grafting
(CLEFTSiS) 2000–2004. Cleft Palate Craniofac J. 2010;47:66–72. A good
discussion article delineating some of the key components associated with
quality and outcome of alveolar bone grafting. The authors relate the
changes to the Scottish Regional Cleft Programme that increased graft
success rate from 58% to 76%.

592.e1
References
References
1. Brauer RO, Cronin TD, Reaves EL. Early maxillary orthopedics,
orthodontia and alveolar bone grafting in complete clefts of the
palate. Plast Reconstr Surg Transplant Bull. 1962;29:625–641.
2. Georgiade NC, Pickrell KL, Quinn GW. Varying concepts in bone
grafting of alveolar palatal defects. Cleft Palate J. 1964;16:43–51.
3. Pickrell K, Quinn G, Massengill R. Primary bone grafting of the
maxilla in clefts of the lip and palate: a four year study. Plast
Reconstr Surg. 1968;41:438–443.
4. Schmid E. Die Annaherung der kieferstempfebei lippen-kiefer.
Gaumensplaten: ihre schadlichen folgen und vermiedung. Forschr
Keifer Geisichtschir. 1955;1:168–180.
5. Schrudde J, Stellmach R. [Primary osteoplasty of defects of the
inferior maxillary arch in cleft palate and harelip in infants;
preliminary report.]. Zentralbl Chir. 1958;83:849–859.
6. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar
and palatal clefts. J Oral Surg. 1972;30:87–92. Landmark article largely
recognized as initiating the popularity of secondary bone grafting. Boyne
introduced the concept in the 1960s, advocating treatment towards the end
of the first decade of life to minimize growth impairment while still
supporting eruption of the adult dentition. Most of the described
principles are still followed today.
7. Skoog T. The use of periosteum and Surgicel for bone restoration in
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at SickKids Hospital, Toronto. Cleft Palate Craniofac J. 2009;46:166–
172. Retrospective study of 116 children with complete unilateral cleft lip
and palate treated since birth. The article quantifies dental anomalies in
permanent dentition associated with complete unilateral cleft lip and
palate and surveys treatment modalities used to address these problems.
13. Bohn A. The course of the premaxillary and maxillary vessels and
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18. Bergland O, Semb G, Abyholm FE. Elimination of the residual
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cleft at the time of secondary alveolar bone grafting on eventual
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21. Cochran DL, Jones AA, Lilly LC, et al. Evaluation of recombinant
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humans. J Periodontol. 2000;71:1241–1257.
22. Guo J, Zhang Q, Wu G, et al. Secondary bone grafting for alveolar
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Database Syst Rev. 2011;(6):CD008050.
23. Liou EJ, Chen PK, Huang CS, et al. Interdental distraction
osteogenesis and rapid orthodontic tooth movement: a novel
approach to approximate a wide alveolar cleft or bony defect. Plast
Reconstr Surg. 2000;105:1262–1272. Detailed case-based review of
interdental transport distraction osteogenesis to treat wide alveolar clefts
by the recognized expert.
24. Rosenstein SW, Grasseschi M, Dado DV. A long-term retrospective
outcome assessment of facial growth, secondary surgical need,
and maxillary lateral incisor status in a surgical–orthodontic
protocol for complete clefts. Plast Reconstr Surg. 2003;111:1–13,
discussion 14–16.
25. Abyholm FE, Bergland O, Semb G. Secondary bone grafting of
alveolar clefts. A surgical/orthodontic treatment enabling a
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Scand J Plast Reconstr Surg. 1981;15:127–140.
26. Rawashdeh MA, Telfah H. Secondary alveolar bone grafting: the
dilemma of donor site selection and morbidity. Br J Oral Maxillofac
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27. Dashow JE, Lewis CW, Hopper RA, et al. Bupivacaine
administration and postoperative pain following anterior iliac crest
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173–178.
28. Vargervik K. Growth characteristics of the premaxilla and
orthodontic treatment principles in bilateral cleft lip and palate.
Cleft Palate J. 1983;20:289–302.
29. Millard DR, Latham R, Huifen X, et al. Cleft lip and palate treated
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1999;103:1630–1644.
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31. Berkowitz S, Mejia M, Bystrik A. A comparison of the effects of the
Latham–Millard procedure with those of a conservative treatment
approach for dental occlusion and facial aesthetics in unilateral and
bilateral complete cleft lip and palate: part I. Dental occlusion. Plast
Reconstr Surg. 2004;113:1–18.
32. Matic DB, Power SM. Evaluating the success of
gingivoperiosteoplasty versus secondary bone grafting in patients
with unilateral clefts. Plast Reconstr Surg. 2008;121:1343–1353,
discussion 1368–1369.
33. Power SM, Matic DB. Gingivoperiosteoplasty following alveolar
molding with a Latham appliance versus secondary bone grafting:
the effects on bone production and midfacial growth in patients
with bilateral clefts. Plast Reconstr Surg. 2009;124:573–582.
34. Grayson BH, Santiago PE, Brecht LE, et al. Presurgical nasoalveolar
molding in infants with cleft lip and palate. Cleft Palate Craniofac J.
1999;36:486–498.
35. Santiago PE, Grayson BH, Cutting CB, et al. Reduced need for
alveolar bone grafting by presurgical orthopedics and primary
gingivoperiosteoplasty. Cleft Palate Craniofac J. 1998;35:77–80.
36. Sato Y, Grayson BH, Garfinkle JS, et al. Success rate of
gingivoperiosteoplasty with and without secondary bone grafts
compared with secondary alveolar bone grafts alone. Plast Reconstr
Surg. 2008;121:1356–1367, discussion 1368–1369. Most recent
retrospective evaluation by the New York University team of GPP
outcomes with and without secondary bone grafting. They concluded that
GPP alone or combined with secondary alveolar bone grafting results in
superior bone levels when compared with conventional secondary alveolar
bone grafting alone.
37. Grayson BH, Shetye PR. Presurgical nasoalveolar moulding
treatment in cleft lip and palate patients. Indian J Plast Surg.
2009;42(suppl):S56–S61.

592.e2
SECTION I
CHAPTER 24 • Alveolar clefts
38. Lee CT, Grayson BH, Cutting CB, et al. Prepubertal midface growth
in unilateral cleft lip and palate following alveolar molding and
gingivoperiosteoplasty. Cleft Palate Craniofac J. 2004;41:375–380.
39. Hathaway RR, Eppley BL, Hennon DK, et al. Primary alveolar cleft
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40. Ross RB. Treatment variables affecting facial growth in complete
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41. Mellon RD, Simone AF, Rappaport BA. Use of anesthetic agents in
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42. Long RE Jr, Spangler BE, Yow M. Cleft width and secondary
alveolar bone graft success. Cleft Palate Craniofac J. 1995;32:
420–427.
43. Witherow H, Cox S, Jones E, et al. A new scale to assess
radiographic success of secondary alveolar bone grafts. Cleft Palate
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44. Kindelan JD, Nashed RR, Bromige MR. Radiographic assessment of
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patients. Cleft Palate Craniofac J. 1997;34:195–198.
45. Feichtinger M, Mossbock R, Karcher H. Evaluation of bone volume
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46. Jia Y, Fu M, Ma L. The comparison of two-dimensional and
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of the lip and palate. J Craniomaxillofac Surg. 1991;19:7–14.
48. Rawashdeh MA, Al Nimri KS. Outcome of secondary alveolar bone
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1331–1337.
49. Hall HD, Posnick JC. Early results of secondary bone grafts in 106
alveolar clefts. J Oral Maxillofac Surg. 1983;41:289–294.
50. Jia YL, Fu MK, Ma L. Long-term outcome of secondary alveolar
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52. Newlands LC. Secondary alveolar bone grafting in cleft lip and
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cleft lip and palate. Eur J Orthod. 2003;25:205–211.
54. McIntyre GT, Devlin MF. Secondary alveolar bone grafting
(CLEFTSiS) 2000–2004. Cleft Palate Craniofac J. 2010;47:66–72. A good
discussion article delineating some of the key components associated with
quality and outcome of alveolar bone grafting. The authors relate the
changes to the Scottish Regional Cleft Programme that increased graft
success rate from 58% to 76%.
55. Chin M, Ng T, Tom WK, et al. Repair of alveolar clefts with
recombinant human bone morphogenetic protein (rhBMP-2) in
patients with clefts. J Craniofac Surg. 2005;16:778–789.
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protein-induced repair of the premaxillary cleft. J Oral Maxillofac
Surg. 2007;65:2136–2141.
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demineralized bone matrix scaffold vs. autologous iliac crest bone
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1107–1115.
58. Dickinson BP, Ashley RK, Wasson KL, et al. Reduced morbidity and
improved healing with bone morphogenic protein-2 in older
patients with alveolar cleft defects. Plast Reconstr Surg. 2008;121:
209–217.
59. Alonso N, Tanikawa DYS, Freitas Rda S, et al. Evaluation of
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1183–1189.
60. Canan LW, Freitas Rda S, Alonso N, et al. Human bone
morphigenetic protein-2 use for maxillary reconstruction in cleft lip
and palate patients. J Craniofac Surg. 2012;23:1627–1633.
61. Neovius E, Lemberger M, Docherty Skogh AC, et al. Alveolar bone
healing accompanied by severe swelling in cleft children treated
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62. Benglis D, Wang MY, Levi AD. A comprehensive review of the
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63. Semb G. Analysis of the Oslo Cleft Lip and Palate Archive: Long-Term
Dentofacial Development. Oslo: University of Oslo; 1991.

SECTION I • Clefts
25 
Orthodontics in cleft lip and
palate management
Alvaro A. Figueroa, Alexander L. Figueroa, Gerson Chinchilla, and Marta Alvarado
SYNOPSIS
■ Patients with orofacial clefts are best treated through a team approach.
■ Close collaboration between the orthodontist and surgeon is critical
during the care of patients with orofacial clefts.
■ A developmental approach needs to be undertaken by orthodontists
treating patients with orofacial clefts.
■ In infancy the orthodontist can support the surgeon with nasoalveolar
molding and maxillary orthopedics.
■ In the primary dentition stage the orthodontist can correct mild to
moderate posterior and anterior crossbites.
■ In the transitional dentition the orthodontist prepares the maxillary arch
prior to bone grafting and premaxillary repositioning.
■ In the full permanent dentition the orthodontist finalizes arch alignment
and coordination.
■ The orthodontist supports the surgeon during planning, preparation of
appliances, and follow-up of patients requiring orthognathic surgery
and/or distraction osteogenesis during adolescence.
■ The orthodontist works closely with other specialists in pediatric
dentistry, prosthodontics, oral, and plastic surgery to rehabilitate the
dental, oral, and facial conditions of patients with orofacial clefts.
■ The application of new three-dimensional surgical and orthodontic
diagnostic and treatment modalities to patients with orofacial clefts is
likely to improve treatment outcomes.
■ Orthodontic movement of primary and permanent teeth through a
recently placed bone graft can enhance osteogenesis.
Introduction
The state of the art for the management of patients with oral
facial clefts requires the use of a multidisciplinary approach,
as various structures, traditionally treated by several special­
ists, are involved. In the oral cavity, the cleft affects not only
the soft and hard palate, but also the alveolus and dentition.
The structural rehabilitation of these patients requires the
surgical correction of the soft- and hard-tissue defects, as well
as the secondary effects of the cleft on maxillary development,
dental support, and dental–occlusal alignment. The role of the
orthodontist in cleft management is essential as the orthodon­
tist assists the surgeon during all stages of reconstructive care:
in the early stages, with presurgical nasal and maxillary
orthopedics; during the transitional dentition stage, with
alignment of the maxillary segments and dentition in prepara­
tion for secondary alveolar bone grafting; during the
permanent dentition and late adolescent years, by obtaining
satisfactory dental and occlusal relationships; and, also to
prepare the dentition for prosthetic rehabilitation and orthog­
nathic surgery, if required. In addition, it has been the role of
the orthodontist to monitor craniofacial growth and dental
development, as well as the treatment effects on these patients
through the use of roentgencephalometry.
With this approach, the management of the cleft patient has
evolved dramatically in recent years. The reason for improved
outcomes is based on refinements in primary and finishing
surgical techniques, as well as timing and incorporation of
other procedures such as presurgical orthopedics, orthodon­
tics, and new prosthetic approaches utilizing resin-bonded
prosthesis and/or osseointegrated implants.
It is our experience that patients treated within the context
of the multidisciplinary approach can obtain excellent out­
comes related to speech, ideal occlusion, satisfactory lip aes­
thetics, and skeletal balance (Fig. 25.1
). However, it is the
secondary cleft nasal deformity that still gives the patient the
“cleft stigmata”.
Fig. 25.1 appears online only.
In recent years, new orthodontic and surgical treatment
modalities have become available that may further improve
outcomes in patients with orofacial clefts. In infancy, this
includes the use of presurgical nasoalveolar molding tech­
niques. In the mixed dentition, novel orthodontic–orthopedic
approaches to correct maxillary hypoplasia are utilized.
Finally, in the permanent dentition, the use of new appliances
and dental materials to facilitate orthodontic treatment, along

593.e1
Introduction
A
B
C
D
E
F
G
H
I
J
K
L
Fig. 25.1  (A–I) Facial and (J–R) intraoral photographs; (S–U) panoramic and (V–X) lateral cephalometric radiographs of a patient with unilateral cleft lip and palate. The
patient underwent lip and palate surgery in infancy. He had an alveolar bone graft in the transitional dentition. He had a diminutive tooth number 7 that was extracted and
substituted with number 6. In late childhood, maxillary deficiency was noted and persisted until adolescence. He had orthodontic preparation of the dentition and underwent
surgical maxillary advancement with rigid fixation. His treatment was successful, with satisfactory facial, occlusal, and skeletal outcomes.
Continued

593.e2
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
M
N
O
P
Q
R
S
T
U
V
W
X
Fig. 25.1, cont’d

594
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
molding by Grayson et al.5–10 The authors have used this
technique since 1995 and have made some modifications.13
Our technique is as follows: the nasoalveolar molding plate
is made utilizing a light-cured orthodontic resin. A loop wire
is incorporated to support the nasal conformer (nasal stent),
made of light-cured acrylic, to reposition the nasal structures.
The nasal stent is covered with soft acrylic to avoid irritation
of the delicate tissues of the nasal mucosa. The palatal aspect
of the plate is covered with soft-tissue liner in order to obtain
perfect adaptation to the maxillary palatal shelves and under­
cuts created by the cleft (Figs. 25.2 & 25.3
). An exact fit of
the plate is required for adequate retention, especially since
we do not rely on external adhesive tape to maintain the plate
in position. We utilize denture adhesive cream, after drying
the plate and the oral mucosa prior to insertion. The parents
are instructed to clean and replace the denture adhesive one
to two times per day. Patients return on a weekly basis for
adjustments to increase the length of the supporting wire and
reshape the nasal stent. While the nasal molding is taking
place, selectively grinding acrylic medial to the palatal shelves
and adding acrylic lateral to the alveolar processes narrows
the distance between the maxillary segments (Fig. 25.4). In
addition, facial taping can be utilized to apply transverse
pressure to the cleft segments and help with the cleft narrow­
ing and nasal molding process (Fig. 25.5).
Figs. 25.2–25.5 appear online only.
The results expected from this technique include reposi­
tioning of the nasal tip towards the non-cleft side with
straightening of the columella and equalizing the height on
the nasal domes as much as possible. In addition, the nasal
stent is adjusted in such a way as to exert lateral pressure on
the lateral nasal wall against the hyperplastic soft tissues
caudal to the lateral nasal cartilage (see Fig. 25.5). This results
in a straighter nose with convex nasal cartilages and flattened
hyperplastic lateral wall vestibular tissues.
At the time of surgery, the surgeon will repair the lip with
medial repositioning of the base of the nose and narrowing of
the nasal domes with tacking of the vestibular tissues to the
lateral nasal wall. We believe that this combined effort will
provide these patients with better noses that will require less
extensive secondary revisions. The outcomes obtained with
this technique are consistent and predictable and these varia­
tions of the molding technique have been incorporated with
favorable results.
In cases that start with severe nasal distortion, we support
the nasal molding with postsurgical nasal stents utilizing
commercially available removable nasal stents.13–15 The stent
is usually kept in place using facial taping (Fig. 25.6
) and
is maintained for at least 2–3 months or for as long as the
patient can deal with it comfortably.
Fig. 25.6 appears online only.
Bilateral cleft lip
The patient with bilateral cleft lip and palate represents the
most challenging condition for the reconstructive team. The
premaxilla is extremely protrusive, the premaxilla and prola­
bium can be of variable size, the columella is deficient or
almost nonexistent, the palatal clefts are wider than usual,
and occasionally, the maxillary palatal shelves are collapsed.
In addition, the nasal domes are wide apart, and the tip pro­
jection is decreased (Fig. 25.7
). It has been our experience
with the application of bone anchorage screws (BAS) to facili­
tate orthodontic tooth movement, are employed. In addition,
the use of distraction osteogenesis to improve the position of
the maxilla, in those cases with severe maxillary hypoplasia,
has become a well-accepted procedure. The availability of
new diagnostic techniques such as digital skull and dental
models, three-dimensional (3D) photogrammetry, lower
radiation computed tomography (CT) scans, cone beam CT
(CBCT), and the development of 3D digital protocols to plan
orthognathic surgery, are now at the forefront of current
orthodontic and surgical approaches. The efforts towards
improvement of orthodontic and surgical treatment strategies
developed for non-cleft patients will benefit the challenging
problems presented by cleft patients and are a welcome addi­
tion to the current treatment protocols. Advances in molecular
biology and biotechnology, along with a better understanding
of their application, have opened doors to new treatment
approaches in medicine and dentistry. These include the clini­
cal use of homologous bone substitutes and application of
bone morphogenetic proteins.
In this chapter, some of the new orthodontic and surgical
strategies that are of benefit to cleft patients will be presented.
The reader is directed to previous publications that deal with
the role of the orthodontist in the management of the cleft
patient to complement the information presented in this
chapter.1–4
Infancy
On many occasions, the surgeon is faced with an infant who
has a severe cleft with marked distortions of not only the
maxillary segments but also the cartilage of the nose. This
situation can occur in both the unilateral and bilateral cleft
lip and palate patient. Since 1995, we have offered the use
of nasoalveolar molding in the treatment protocol of those
cleft patients presenting with premaxillary protrusion, hypo­
plastic columellas, and moderate to severe nasal distortions,
following the general principles reported by Grayson and
associates.5–10 These protocols utilize premaxillary and maxil­
lary orthopedics with the additional purposes of not only
aligning the maxillary and premaxillary segments, but also to
reposition the nasal cartilages prior to lip repair.
Unilateral cleft lip
Evaluation of the cleft nose demonstrates the presence of
distorted nasal cartilage with deviation of the nasal tip
towards the non-cleft side and severe angulation of the colu­
mella also to the non-cleft side. In addition, we have observed
that the soft tissues caudal to the lateral nasal cartilage may
be hyperplastic and prominent. Repair of the lip under these
conditions, even with surgical repositioning of the nasal car­
tilages, results in a suboptimal nasal morphology, even though
the lip repair is satisfactory. It is for this reason that we have
now embarked on the process of orthopedic repositioning of
the nasal cartilages, columella, nasal tip, and lateral wall of
the vestibule in order to provide these patients with the best
possible primary nasal reconstruction with less invasive sur­
gical techniques. The procedure of presurgical infant nasal
remodeling utilizing a modified intraoral plate was first
described by Bennun and co-workers in Argentina.11,12 Since
then, it has been popularized in the US as nasoalveolar

594.e1
Infancy
Fig. 25.2  Dental cast of an infant with unilateral cleft
lip and palate (A) utilized to fabricate an acrylic palatal
plate (B) to which a long and straight stainless-steel
wire is attached to fabricate the nasal stent required for
molding the nasal structures (arrows) (C). The wire is
measured relative to the position and height of the
nose (D).
A
B
C
D
Fig. 25.3  The wire is cut and bent, leaving an
“adjustment loop” (lower arrow) and a terminal loop
(upper arrow) to attach the nasal conformer part of the
stent (A). The end of the wire is covered by hard
acrylic and lined with soft acrylic to fabricate the nasal
conformer (arrows) (B). Patient without (C) and with
(D) nasoalveolar molding plate in place, note elevation
of the cleft nostril.
A
B
C
D

594.e2
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
A
B
C
Fig. 25.4  Facial photographs of a patient with unilateral cleft lip and palate before (A), after nasoalveolar molding and before lip surgery, frontal view (B) and worm’s-eye
view (C). Intraoral views before (D) and after (E) nasoalveolar molding. Note alveolar and palatal cleft narrowing and improved nasal form after nasoalveolar molding and
prior to lip surgery. Frontal facial photograph after nasoalveolar molding and lip surgery (F).
D
E
F

594.e3
Infancy
A
Fig. 25.5  Patient with unilateral cleft lip and palate undergoing nasoalveolar
molding (A) and with facial taping (B). Note rounding of the alar cartilage around
the nasal stent.
B
A
Fig. 25.6  After nasoalveolar molding and lip surgery a nasal stent is inserted (A).
Note base tape adhering to the cheeks, used to secure the nasal stent tape (B) and
to prevent skin irritation and frequent tape replacement.
B

595
Transitional dentition
been used for a few years, and there are not enough long-term
data to demonstrate the effects of the technique on the fully
developed nasal structures. However, some patients are in the
midteen years, and the clinical impression at this time is that
they will require less extensive nasal revision procedures at
the completion of facial growth (Fig. 25.10
).
Fig. 25.10 appears online only.
Primary dentition
Orthodontic treatment at this stage is limited to the correction
of certain posterior crossbites and anterior crossbites of mild
to moderate degree.
Posterior crossbite
In the cleft patient, posterior crossbites are of both skeletal and
dental origin. They are skeletal because the maxillary seg­
ments are usually collapsed after cleft palate surgery, espe­
cially in the canine region. In most instances, this change in
arch form occurs prior to the eruption of the primary canines;
therefore, at the time of eruption of these teeth, the maxillary
cleft-side primary canine erupts medially to the lower one. In
addition, this early relationship causes minor palatal displace­
ment of the maxillary primary canine and labial displacement
of the mandibular one.3 This is an important observation, as
this is the reason why cleft patients in the primary dentition
rarely have occlusal or functional shifts. Patients in whom an
occlusal shift is detected are those who are candidates for
either selective tooth grinding or expansion procedures.
Expansion can readily be accomplished, but it should be
noted that, after it is completed, unless a bone graft is placed,
it has to be retained until the time of alveolar reconstruction
with a bone graft. For this reason, we prefer to delay trans­
verse expansion in the primary dentition until the patient is
older and just prior to secondary alveolar bone-grafting pro­
cedures usually undertaken in the transitional dentition.
Anterior crossbite
Anterior crossbite of mild to moderate degree can be managed
in the primary and transitional dentition stages utilizing
elastic protraction forces delivered through a facial mask.18–20
However, if it is noted that this crossbite is related to a moder­
ate to severe skeletal maxillary hypoplasia, the patient is best
managed with a surgical approach. If it is felt that the maxil­
lary advancement is important at an early age due to its
severity, it can be instituted by means of distraction
osteogenesis.
Transitional dentition
This is the developmental stage in which a cleft patient,
involving the alveolus, will receive the next surgical procedure
after lip and secondary palate repair. In most instances, the
dentition around the cleft presents severe malposition, limit­
ing surgical access to the alveolar site (Fig. 25.11
). For this
purpose, the dentition adjacent to the cleft has to be reposi­
tioned, preparing the cleft site for the secondary alveolar bone
graft. Reconstruction of the cleft alveolus and anterior aspect
of the maxilla is deferred until this stage, in an attempt to
that, in patients with bilateral cleft lip and palate, with a
protrusive premaxilla, it becomes imperative that the premax­
illa is repositioned into a more favorable relation with the
maxillary segments in order to achieve definitive lip closure
with minimal tension. If this is not done, a poor repair or
failure with unfavorable consequences may occur. For this
purpose, we have successfully utilized premaxillary orthope­
dics with an intraoral appliance that is retained with denture
adhesive and has an elastic strap for premaxillary retrac­
tion.16,17 This approach has allowed the surgeon to close the
lip satisfactorily (Figs. 25.8 & 25.9
).
Figs. 25.7–25.9 appear online only.
In the bilateral cleft lip and palate patient the approach
requires repositioning of the premaxilla prior to the nasal
molding technique. For the last 20 years we have used a
self-retaining intraoral plate17 that has been modified from the
original design.16 This modification allows for easy adjust­
ments and fewer frequent patient visits.
Grayson and coworkers6–8,10 have utilized nasoalveolar
molding for bilateral clefts. The appliance was intended to
retract the premaxilla as well as molding the nasal cartilage
and elongating the columella. Their plate design included
retention through extraoral taping and elastics. We have
modified the design utilizing our principles of a self-retained
appliance13,16,17 to avoid using facial taping to support the
prosthesis. A light-cured resin plate is constructed to which
orthodontic buttons or custom-formed wires are attached for
retraction of the premaxilla with the elastomeric band. In
addition, the plate is relined with soft-tissue conditioner for
close adaptation to the palatal tissues. After premaxillary
retraction and repositioning are completed, the plate is modi­
fied by adding two wires that go into each nasal vestibule.
The ends of the wires are bent in a loop and are covered with
a light-cured acrylic covered with soft denture lining material
(nasal stents). In addition, loops are bent about the level of the
superior aspect of the prolabium for attachment of an elasto­
meric chain that has been covered with a soft-tissue denture
liner. The purpose of the elastomeric chain across the prola­
bium is to hold it down, while the nasal prongs at the end of
the wires are gradually elevated, lifting and medially reposi­
tioning the nasal domes and, at the same time, elongating the
hypoplastic columella (see Fig. 25.8
). The plate is used 24
hours a day, is removed daily for cleaning, and is held in
position with the aid of a denture adhesive cream. In addition,
the palatal aspect of the plate can be modified by adding
material on the lateral aspects of the plate and removing
acrylic on the medial aspects. This will allow for gentle and
gradual repositioning of the maxillary segments, resulting in
narrowing of the cleft. This technique has given the surgeon
an improved situation for not only obtaining adequate lip
repair but also providing a better situation for primary nasal
reconstruction with remodeling of the nasal domes and nasal
tip and elongation of the hypoplastic columella. The main
advantage of this procedure is that it eliminates the need for
secondary procedures for columella elongation in the early
childhood years. All of the patients in whom this technique
has been used have adjusted extremely well to the use of the
appliance and the families have been extremely pleased with
the results (see Fig. 28.9
), as well as with the ease in which
the orthopedic phase is carried out.
The described protocol has been well tolerated by patients
and readily accepted by parents. This treatment protocol has

595.e1
Infancy
Fig. 25.7  (A) Frontal, (B) profile, and (C) intraoral photographs of a patient with bilateral cleft lip and palate with protrusive and deviated premaxilla. She underwent
premaxillary repositioning with an intraoral plate with elastomeric chain (D, E, F). Frontal (G), Profile (H) and nasal submental view (I) after premaxillary repositioning and
prior to nasal molding. Note reduction of premaxillary asymmetry and protrusion as well as improved nasal form.
A
B
C
D
E
F
G
H
I

595.e2
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
A
B
Fig. 25.8  After initial premaxillary repositioning, patient with bilateral cleft and palate undergoing nasal molding. Note two nasal stents added to the plate with an anterior
elastomeric chain (A, B). While the elastomeric chain is holding the premaxilla and prolabium down and back, the nasal stents elevate the nasal tip, repositioning the nasal
domes towards the midline and elongating the columella (C–E).
C
D
E

595.e3
Transitional dentition
A
B
C
D
E
F
G
H
I
Fig. 25.9  Frontal, profile, and nasal photographs of a patient with bilateral cleft lip and palate who underwent presurgical nasoalveolar molding treatment and primary lip
repair. Comparison of before (A–C) and after (D–F) nasoalveolar molding photographs illustrate reduction of premaxillary asymmetry and protrusion as well as improvement
of nasal asymmetry. A satisfactory lip and nasal repair was obtained soon after lip surgery (G–I). Four years after surgery (J–L), the patient maintains excellent lip line,
nose/lip relations, nasal symmetry, and projection.
J
K
L

595.e4
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
Fig. 25.10  Long-term follow-up of a patient with unilateral cleft lip and palate treated with presurgical
nasoalveolar molding, and only primary lip and palate repair and alveolar bone grafting. Close-up photos of the
nose before (A) and after (B) nasoalveolar molding, and feeding with the nasoalveolar molding prosthesis in place
(C). Facial photos before treatment (D), postsurgery at 2 (E), 9 (F) and 16 (G) years of age. Note satisfactory
outcome with nice lip line and stable nasal symmetry.
A
B
C
D
E
F
G
Liou and Tsai21 have introduced an intraoral technique for
orthopedic advancement of the maxilla. They used a spring
system with highly flexible wires to apply constant anterior
pressure to the maxilla. Simultaneously they used a screw-
type expander, which is regularly activated. After the screw
reaches its limit, it is then turned backwards (contraction).
This constant action results in activation of the circumaxillary
suture complex, and in this way maxillary protraction is
obtained.22 The technique has been applied to both cleft and
non-cleft patients with impressive outcomes superior to
conventional face mask therapy.21

596
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
with a maxillary expander. The expander commonly used in
our protocol is the quad helix expander (Fig. 25.13). We rarely
use a screw expander unless it is observed that the palatal
tissues are severely scarred (Fig. 25.14). Fortunately, with the
use of more delicate surgical techniques, this latter situation
is uncommon.
Fig. 25.12 appears online only.
The expansion required for alveolar bone grafting should
provide well-aligned maxillary segments with a minimal
increase in the size of the alveolar gap. Wider alveolar gaps
are difficult to close using local flaps.28 In cases in which the
clinician determines that the required expansion of the maxilla
or repositioning of the premaxilla will create a wider gap
between the maxillary segments, expansion and bone-grafting
procedures are deferred until adolescence. At this time, the
maxillary segments can be surgically mobilized and approxi­
mated, allowing for closure with local flaps at the time of final
orthognathic surgery.
After the maxillary segments and dentition are placed in
their ideal positions, the patient is referred for secondary
alveolar bone grafting.29 Presurgical orthodontics in prepara­
tion for this reconstructive stage can be completed within a
period of 6–12 months. Immediately prior to the bone graft,
all appliances over the palate are removed and the labial
aspects of the orthodontic wire are segmentalized for surgical
access. In addition, supernumerary or primary teeth in the
minimize the growth restriction resulting from surgical
trauma and scarring.23–25
Fig. 25.11 appears online only.
If it is determined that the patient requires orthodontic
treatment for preparation of the surgical site, it should be initi­
ated based on dental development of the permanent teeth to
be moved rather than chronological age.3,13,26 It is known that
cleft patients present with delay of dental development and
eruption.26,27 Orthodontic treatment should not be initiated
until the near-complete root development of the incisors, on
which orthodontic brackets will be placed (see Fig. 25.11M–O).
Adherence to this guideline will result in minimal resorptive
changes of the maxillary incisor roots. If the necessary treat­
ment for secondary bone grafting of the maxilla is based on
dental development rather than chronological age, a safeguard
for the adverse effects of surgery on growth is added. Our
own studies26 indicate that development and eruption of the
cleft lateral incisor are markedly delayed when compared
with a contralateral incisor (see Fig. 25.11M–O). This observa­
tion allows for placement of orthodontic appliances on the
remaining incisors while the cleft lateral incisor has not yet
erupted. When a viable cleft maxillary lateral incisor is present,
this ensures its preservation and adequate bone support for
eruption of both lateral incisor and canine after the bone graft.
The expansion of the arch can also be done with this appli­
ance (Fig. 25.12
), but occasionally it has to be supported
Fig. 25.13  Patient with unilateral cleft lip and palate before orthodontic treatment in preparation for bone grafting (A), during expansion with quad helix expander (B), and
after bone grafting with erupted cleft-side canine and peg cleft lateral incisor erupting palatal (C). Note arch alignment after expansion and adequate arch form after
expansion, bone grafting, and orthodontics.
A
B
C
Fig. 25.14  Intraoral views of a patient with bilateral cleft lip and palate with arch collapse (A). A rigid screw expander was used (B). After expansion (C), note improvement
on arch form and opening of alveolar spaces in preparation for bone grafting.
A
B
C

596.e1
Transitional dentition
Fig. 25.11  Patient with unilateral cleft lip and palate in the transitional dentition prior to orthodontic preparation for alveolar bone grafting (A–C), after orthodontic treatment
(D–F), and after bone graft (G–I). Note alignment of the dental arch with a simple segmental edgewise orthodontic appliance. (J–L) Occlusal views at similar stages. Note
missing lateral incisor and retained primary canine in the cleft area (arrow) (J). This tooth was extracted prior to surgery. Note aligned arch prior to surgery (K). After
surgery, the permanent canine erupted through the bone-grafted area (arrow) (L). (M–O) Panoramic radiographs at similar stages: note in the pretreatment radiograph (M)
complete apical root development of the maxillary incisors (single arrow), retained primary canine and missing lateral incisor (dotted arrow) and unerupted maxillary left
canine (double arrows). During orthodontics (N) and after bone grafting (O), note intact maxillary incisor root apices (single arrow) and maxillary left canine erupting
through the bone graft (double arrows) (O).
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
Continued

596.e2
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
P
(P) After treatment an interim prosthesis was given to the
patient replacing the missing lateral incisor (arrow).
Fig. 25.11, cont’d
When preparing the maxillary arch for a bone graft, it is
necessary only to address the malposition of the incisors and
the anterior collapse of the maxillary arch. The first stage is
usually obtained through the use of a bonded edgewise appli­
ance (see Fig. 25.11A–L). The use of new self-ligating brackets
and highly flexible orthodontic arch wires permits slow and
highly efficient tooth movement with minimal trauma and
risk of root resorption. As the teeth slowly move, the sur­
rounding thin alveolar bone remodels, maintaining adequate
periodontal support even for those teeth adjacent to the cleft.
A
B
Fig. 25.12  (A–D) Maxillary arch expansion and dental alignment in a unilateral cleft lip and palate patient with severe scarring and collapse. Treatment was achieved in a
slow fashion with the use of highly flexible wires and a self-ligating bracket.
C
D

597
Transitional dentition
it is convenient to do the bone grafting in the transitional
dentition or if it should be done in combination with future
orthognathic surgical procedures. Patients in whom there is
marked tissue deficiency, including maxillary hypoplasia and
congenitally missing teeth, are likely candidates for postpone­
ment of the traditional approach with secondary alveolar
bone grafting, and will be treated later on in the permanent
dentition in combination with orthognathic surgery. If it is
deemed important to preserve the dentition adjacent to the
alveolar cleft, orthodontics are therefore indicated, even in the
presence of a skeletal disharmony. The purpose of the orth­
odontic treatment is then to prepare the dentition for the
alveolar bone graft and also to coordinate the maxillary arch
to the mandibular arch for future orthognathic surgery that
will be performed in the teen years. This approach minimizes
the required orthodontic treatment prior to orthognathic
surgery in the adolescent years.
Orthodontic tooth movement to regenerate a
homologous lyophilized bone graft combined
with platelet rich plasma to reconstruct the
alveolar cleft: “Chinchilla–Asensio Approach”
Advances in molecular biology and biotechnology now
offer the possibility of accelerated healing and tissue
regeneration.30–38 At the Centro Infantil de Estomatología in
Antigua, Guatemala some of these new advances for the
treatment of cleft lip and palate patients have been incorpo­
rated. The use of lyophilized homologous bone combined
with autologous platelet rich plasma, in combination with
graft stimulation by orthodontic movement of primary
teeth adjacent to the cleft (usually primary canine), has
shown favorable graft incorporation with excellent clinical
outcomes.
surgical site are extracted 8–12 weeks prior to surgery. This
will provide the surgeon with intact gingival tissues for
proper coverage of the bone graft.
The presence of alveolar bone is dependent on the presence
of teeth. When the lateral incisor is present, with adequate
crown and root anatomy, and in favorable position, every
attempt should be made to preserve it. If the lateral incisor
erupts through the bone graft, suitable alveolar bone will be
available in the alveolar ridge as well as for the erupting
canine (Fig. 25.15). If the permanent lateral incisor on the cleft
side is missing or needs to be extracted due to its poor anatomy
or position (see Fig. 25.11J–O
), then the actively erupting
canine could take its place and preserve the reconstructed
alveolus.
Orthodontic treatment can be restarted 8–12 weeks after
bone graft surgery. As soon as appropriate maxillary arch and
dental relations are achieved, the orthodontic appliances are
removed and the patient is placed in retention until there is
full permanent dentition. Teeth that were severely rotated
prior to treatment need to be retained. Absent teeth can be
temporarily replaced with a removable prosthetic appliance
to improve aesthetics and limit the effects on speech produc­
tion (see Fig. 25.11P
).
Patients treated with the protocol outlined above complete
the preparatory phase of orthodontic treatment in the preteen
or early teen years. Patients are followed every 6 months to
determine their craniofacial growth and dental development,
especially eruption of the maxillary lateral incisor and canine
on the cleft side. Occasionally, the maxillary canine is impacted
and requires surgical exposure and orthodontic incorporation
into the arch as the child is in the full permanent dentition.
Impacted or severely malpositioned cleft-side maxillary
lateral incisors are usually extracted (see Fig. 25.11J–L
).
Finally, if it is determined that there is anteroposterior
skeletal disharmony, the reconstructive team has to decide if
Fig. 25.15  (A–D) Patient with right
unilateral cleft lip and palate with
permanent maxillary lateral incisor and
canine present. After the bone graft the
canine erupted with adequate gingival
support. The lateral incisor erupted later on
spontaneously (arrow) and was incorporated
into the dental arch. At the completion of
treatment the tooth was cosmetically
enlarged.
A
B
C
D

598
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
molars. This set-up provides sufficient stability to the appli­
ance (Fig. 25.16).
Alignment of the maxillary dentition is completed with a
series of highly flexible to rigid arch wires. The initial level
and alignment process is slowed by replacing arches at no less
than at 8-week intervals, preventing possible initiation of
rapid root resorption of the primary teeth. Once the patient is
in a heavy archwire (rectangular gauge 0.016″ × 0.022″ or
heavier) and the segments stabilized, referral to the surgeon
is done. Primary teeth adjacent to the alveolar cleft with root
resorption, significant mobility, or caries are extracted at least
2 months prior to the alveolar bone graft surgery to allow
gingival tissue healing. Prior to surgery, the orthodontic arch
is removed, so as not to interfere with surgical access. In both
unilateral and bilateral cases it may be necessary to replace
the arch immediately after the procedure.
Surgical protocol
The incision design of Abyholm et al. is utilized to access
and prepare the alveolar cleft site.29 Once the nasal floor
and palatal aspect of the alveolar cleft are closed, a gelatin
plasma membrane is applied to the closed walls of the
alveolar cleft. Lyophilized homologous bone, mixed with
platelet rich plasma into a malleable and easy to manipulate
paste, is applied into the defect. Two additional layers of
gelatin plasma membrane are applied over the bone.31,32,35,36,42
To close the alveolar border, a horizontal mattress suture
is used to hold one or two of the fibrin membranes and,
in this way, achieve a hermetic seal. After closure, addi­
tional liquid plasma is injected into the alveolar cleft site
(Fig. 25.17).32,42
This unique protocol includes orthopedic and orthodontic
alignment of the arch as early as 4 years of age. The bone graft
is performed between 5 and 8 years of age; and, 3 months after
the graft, orthodontic movement of teeth, adjacent to the
grafted site, is initiated to stimulate incorporation of the graft.
To date, 66 cases have been treated in this fashion, 54 unilateral
and 12 bilateral alveolar clefts with a follow-up of 7 years.
Orthodontic protocol – pre-graft
Pre-graft orthopedics and orthodontics
The orthodontist must assure that the dentition is healthy
prior to treatment. Patients can be in full primary dentition or
early transitional dentition to initiate the protocol. As indi­
cated previously in the chapter, the objectives of orthopedic
and orthodontic treatment at this stage are to align the maxil­
lary segments, correct dental malpositions, improve arch
form, and facilitate access to the cleft alveolus at the time of
surgery.
Careful assessment is done of the periodontal condition,
degree of apical development, root inclination, and proximity
of primary and permanent teeth to the alveolar cleft. In
younger children, special attention is given to the root status
(resorption) of the maxillary primary incisors and primary
canine(s) adjacent to the alveolar cleft(s).26,39–41
After maxillary arch expansion, a transpalatal arch bar with
anterior extensions is used for retention, making sure to keep
the extensions off the surgical site. Standard orthodontic
brackets of appropriate size (i.e. mandibular incisor brackets)
are placed on as many anterior teeth as necessary. Tubes are
designed on the transpalatal bar bands of the primary second
Fig. 25.16  Frontal (A) and occlusal (B) views
of a patient with a complete right unilateral
cleft lip and palate in the primary dentition.
Note orthodontic brackets in all maxillary
primary teeth and transpalatal bar used to
maintain the expansion. Frontal (C) and
occlusal (D) views of a patient with bilateral
cleft lip and alveolus in the primary dentition.
Note orthodontic brackets on the maxillary
anterior primary teeth and transpalatal bar used
to maintain the expansion.
A
B
C
D

599
Transitional dentition
frequently used in periodontally compromised patients,
cases requiring dental implants, and prosthetic
rehabilitation34,35,37,46 (Figs. 25.19, 25.20 & 25.21).
Completing the post-graft orthodontic treatment may take
between 6 and 8 months. The total duration of treatment can
be between 12 and 18 months, including orthodontics and
bone grafting. After this period, patients undergo routine
follow-up until they are ready for their final orthodontic treat­
ment in the teen years, as shown later in this chapter.
Outcomes and benefits
To date, 66 patients with alveolar clefts (52 unilateral, 14
bilateral), between 5 and 8 years of age, have been success­
fully treated with this approach. The average age for bone
grafting was 6 12 years. Some 52% of the cases underwent
bone grafting during primary dentition, and the rest during
the early transitional dentition. Although many of the patients
were younger than the usual time for traditional secondary
alveolar bone grafting, they tolerated the orthodontic treat­
ment surprisingly well. A significant amount of time is spent
educating the children and parents on the importance of good
oral health, hygiene, and excellent care of their orthodontic
appliances.
Orthodontic protocol – post-graft
Patients are evaluated 4 and 20 days after the alveolar bone
graft. At 3 and 6 months radiographs are obtained of the site.
Two situations may occur, and are based on the dental
development of the patient and the presence of primary and/
or permanent teeth, supernumerary, or peg-shaped incisors.
1. The cleft permanent central and lateral incisor,
supernumerary, or peg shaped lateral incisor may erupt
spontaneously; and, subsequently the maxillary
permanent canine also erupts naturally (Fig. 25.18).
2. If the position of the cleft maxillary canine is high in the
bone, the primary canine is moved towards and through
the recently reconstructed alveolar cleft site. This is
done by means of light orthodontic forces (60 grs) with a
nickel titanium open spring. The movement of the
primary canine through the bone grafts regenerates the
newly grafted bone and increases the alveolar ridge
bone volume. This is possible due to the ability of the
periodontal ligament to generate bone during
orthodontic tooth movement.43–45 Also a supernumerary
or peg-shaped lateral with adequate root length can be
moved through the bone graft for the same purpose.
Moving teeth to regenerate bone is a procedure
Fig. 25.17  “Asensio surgical protocol”. (A) Incision
and nasal floor closure. (B) Insertion of plasma
membrane. (C) Mixture of homologous lyophilized
bone and liquid plasma. (D) Compacting the graft into
the alveolar cleft. (E,F) Placement of two plasma
membranes. (G) Closure of the flap. (H) Liquid
plasma injection.
A
B
C
D
E
F
G
H

600
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
adequate length (Fig. 25.22A). The vertical height and thick­
ness of the alveolar bone ridge has been measured radio­
graphically to be close to the length of the root of the primary
canines (11 mm) and the thickness of its diameter (5–6 mm)
(Fig. 25.22B). In addition, biopsies have been obtained in a few
cases to uncover canines for faster incorporation of the canine
into the arch and have revealed viable trabecular bone
(Fig. 25.23).
Available radiographic evidence demonstrates that the
primary canine is usually not affected by accelerated root
resorption after being moved distances between 5 and 8 mm
(Fig. 25.24). The process of radicular resorption and exfolia­
tion is usually no different to that observed in patients without
clefts. However, in some cases, premature exfoliation is noted
in conjunction with earlier eruption of the cleft side canine.
Other considerations
The possible disadvantages of this approach may include the
need to select the patients at a time when the roots of their
A
B
Fig. 25.18  (A) Initial occlusal radiograph of patient aged 5 years 7 months with left unilateral cleft lip/palate. Note absence of the contralateral maxillary permanent lateral
incisor and rotation of the cleft-side central incisor towards the cleft. (B) Six months after alignment of the arch and prior to bone graft. (C) After exfoliation of the maxillary
primary central incisors, the cleft-side maxillary incisor is erupting into the bone graft with better alignment. (D) The occlusal radiograph demonstrates the orthodontic
appliance and adequate osseous bridge to support orthodontic dental movement.
C
D
The benefits of this approach are numerous, including no
harvest site and eliminating donor site morbidity; taking
advantage of the osteogenic regenerative capacity of the
periodontal ligament during orthodontic tooth movement;
providing and maintaining vertical and horizontal alveolar
bone level until the permanent teeth erupt; facilitating tooth
(lateral incisors and canines) eruption naturally into the
reconstructed alveolar bone; allowing the permanent maxil­
lary lateral incisor and/or canine to follow the orthodontic
movement of the primary canine, thereby enhancing natural
eruption; obtaining closure of the oro-nasal fistula; providing
adequate attached gingiva to support dental eruption and
periodontal health; and, finally, possibly improving self
esteem as young children can attend school without the
stigma of a cleft-related malocclusion, especially maxillary
anterior dental alignment.
For the protocol to be successful, the maxillary arch needs
to be aligned, the alveolar cleft should not be too wide to
allow closure with local flaps, and the root of the primary
canine (to be moved into the grafted site) needs to be of

601
Transitional dentition
technique. However, obtaining plasma is relatively simple for
many teams. Once the cost for the processing equipment is
covered, the costs are minimal. Homologous lyophilized bone
is easily found through medical suppliers.
In patients with wider clefts, the pyriform aperture may
require higher bone placement to support the alar base. It is
not certain if the bone graft performed in this manner can
provide sufficient bone for this purpose. However, if the nasal
maxillary primary canines are intact. Patients treated under
this protocol tend to be younger, therefore appropriate man­
agement techniques need to be applied to allow the young
patients to accept, tolerate, and cooperate with the orthodontic
treatment. Early radiographic examinations and education to
referring health professionals need to be conducted. The cost
and access to the lyophilized homologous bone and the equip­
ment to process the plasma may affect the decision to use this
Fig. 25.19  Schematic representation of the
orthodontic/surgical protocol. (A) Case with a
unilateral alveolar cleft in the primary dentition,
with a microdontic cleft-side permanent lateral
incisor. (B) Placement of orthodontic appliances
on the primary maxillary teeth. (C) Closure of
alveolar cleft with lyophilized homologous bone
and platelet rich plasma. (D,E) Bone-graft
stimulation and regeneration through orthodontic
movement of the cleft primary canine. Note the
natural mesial migration of the permanent
maxillary cleft-side canine taking the position of
the missing permanent lateral incisor. (F)
Undergoing finishing orthodontics with space
closure. (G) Final outcome with substitution of
the missing permanent lateral incisor by the
canine.
A
B
C
D
E
F
G
A
Fig. 25.20  Mesial movement (arrows) of the cleft side primary canine through the recently grafted alveolar cleft in a case missing the permanent maxillary lateral cleft-side
incisor. A nickel titanium spring (60 grs) is used to move the tooth. Lateral view (A), occlusal view (B).
B

602
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
reconstructed alveolar cleft. The functional and aesthetic
benefits have been favorable and are demonstrated in the
following case with a complete unilateral cleft lip and palate
(Fig. 25.25
).
Fig. 25.25 appears online only.
Permanent dentition
At the time of near complete or complete permanent denti­
tion, the orthodontist must perform definitive orthodontic
treatment for the cleft patient. The goals are no different than
those for non-cleft patients, but certain conditions must be
kept in mind during treatment planning. These include arch
length requirements and need for dental extractions in cases
of severe crowding; integrity of the dentition and supporting
floor is properly addressed during the primary lip repair, this
may not be a factor. Although this approach is used in non-
cleft patients to build up bone in preparation for placement
of osseointegrated fixtures, it is not known if sufficient bone
is created to support a future implant in the alveolar cleft
region. However, the main purpose of this early approach is
to allow migration of the patient’s own teeth and, in this way,
eliminate the need for prosthetic replacements.
This approach has been successful in the rehabilitation of
the alveolar cleft. Integration of the graft is possibly enhanced
by the osteogenic stimulation of the orthodontic movement of
the primary cleft canine into the graft, as well as through
natural dental eruption of adjacent teeth. It has resulted in
satisfactory bone levels in both the vertical and horizontal
dimension, as well as adequate levels of attached gingiva and
healthy periodontal condition of the teeth adjacent to the
A
Fig. 25.21  Occlusal views of the case shown in Fig. 25.20. (A) After movement of the cleft-side primary canine through the alveolar graft a peg-shaped lateral incisor
erupted spontaneously. Note on the left side or non-cleft side the absence of a permanent canine. This tooth required extraction due to an abnormal short root. (B) After
extraction of the cleft-side peg-shaped incisor the permanent canine erupted spontaneously and was orthodontically moved to the position of the missing maxillary lateral
incisor. Note a consolidated and well-aligned maxillary arch.
B
Fig. 25.22  (A) CBCT scan with longitudinal root measurement of the cleft-side maxillary primary canine prior to bone graft surgery. The average length of this tooth is
11 mm. (B) Coronal section demonstrating a 5.37 mm anteroposterior width of the bony bridge after bone graft and movement of the primary canine through it. The average
bucco-lingual diameter of the canine is 5.5 mm.
A
B

602.e1
Permanent dentition
A
B
C
D
E
F
Fig. 25.25  (A) Panoramic radiograph of a 6-year-old female patient with complete left unilateral cleft lip and palate in the early transitional dentition stage. She is missing
the second right maxillary second bicuspid and has a peg cleft-side permanent maxillary lateral incisor. The cleft-side primary canine had a stainless steel crown and had
signs of early root resorption compared to the contralateral canine. This tooth was scheduled for extraction. (B–E) Frontal intraoral photographs. (B) Pre-treatment view.
(C) During expansion and maxillary arch dental alignment. (D) After arch alignment and eruption of the peg-shaped lateral incisor and prior to the bone graft. (E)
Orthodontic movement of the peg-shaped lateral incisor through the bone graft. After complete mesialization the patient was placed in retention to allow for eruption of the
permanent dentition and finalize orthodontic treatment. (F) A year later treatment was re-initiated, the peg-shaped lateral incisor extracted, and the cleft-side permanent
canine moved into the position of the lateral incisor. All posterior teeth in that quadrant were moved forward to consolidate the arch. Note adequate gingival tissues and
ideal occlusal relations.
Continued

602.e2
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
G
H
I
J
(G–J) Occlusal view of the maxillary arch during various stages of treatment. (G) In early transitional dentition prior to treatment. (H) Maxillary
expander and orthodontic brackets to align the arch and dentition prior to bone graft surgery. Note eruption of the peg-shaped maxillary cleft-side lateral incisor after
extraction of the primary canine with stainless steel crown. (I) After the alveolar bone graft the cleft-side lateral incisor has been moved through the graft next to the
cleft-side maxillary central incisor. Note thickness of the alveolar ridge and transpalatal bar used for retention after expansion. (J) Finishing stages of orthodontic treatment
after extraction of the peg-shaped maxillary cleft-side lateral incisor and incorporation of the cleft-side maxillary canine in its position. The maxillary arch is well aligned and
spaces have been consolidated.
Fig. 25.25, cont’d

603
Permanent dentition
with class I cuspid and molar relationships with ideal overjet
and overbite (Figs. 25.1 & 25.27A
). If the cleft lateral incisor
is missing, the clinician must decide if this tooth needs to be
replaced with a prosthesis or the space closed with orthodon­
tics or with a combined surgical–orthodontic approach.
Prosthetic replacement is usually reserved for those cases in
which ideal class I cuspid relationships and overjet and over­
bite are present. In these cases, if the anatomy of the adjacent
teeth to the dental gap is sound, a bonded prosthesis or an
osseointegrated fixture can be utilized.1–3,13,47,48
In those cases with a missing lateral incisor, in which the
maxillary canine has migrated forward and is erupting into
the grafted alveolar ridge (see Fig. 25.29), one must consider
substituting the lateral incisor with the canine, and moving
structures, especially for teeth adjacent to the alveolar cleft;
unusual dental positions, such as impactions; dental transpo­
sitions; congenitally missing or severely abnormal teeth that
may need to be extracted requiring replacement either with a
prosthesis or with orthodontic space closure, especially in the
cleft region; maxillary and mandibular dental midlines and
their relation to the facial midline; and anterior/posterior,
transverse, and vertical relationships of the maxilla and
mandible to each other and to the face.1–3,13
The introduction of new flexible wires and self-ligating
appliances permits physiologic forces allowing favorable soft-
tissue and bone remodeling responses, especially on those
severely malpositioned teeth adjacent to the cleft (Figs. 25.12
& 25.26). Every attempt should be made to complete the case
Fig. 25.23  (A) View of the grafted alveolar site 12 months after eruption of adjacent permanent teeth in a case in which the primary canine was moved to stimulate and
regenerate the graft. The permanent cleft-side canine had delayed eruption. (B) It became necessary to expose it and move into the arch with orthodontic forces. The
removed bone was histologically examined and revealed dense well-trabeculated bone.
A
B
Fig. 25.24  (A) Radiographic sequence demonstrating the alveolar cleft prior to bone graft. Note the primary cleft-side primary canine with a bracket and adjacent to the
cleft. (B) Orthodontic movement of the primary canine for stimulation and osseous regeneration of the bone graft. Note preservation of the primary canine root and
spontaneous mesial migration of the permanent canine. (C) Completed movement of the permanent canine into the position of the missing maxillary cleft-side permanent
lateral incisor.
A
B
C

604
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
Fig. 25.26  Sequential occlusal and frontal intraoral views of an adult patient with repaired unilateral cleft lip and palate. Before treatment note severely collapsed maxillary
arch and crowding in both arches. A peg left maxillary incisor was present. Due to severe crowding dental extractions of teeth number 4, 7, 21, and 28 (arrows) became
necessary. Highly flexible wires and a self-ligating bracket system were used from the beginning of treatment (A, B, C). Soon after leveling the gingival condition of the
maxillary left central incisor was healthy. After further alignment and space closure the gingival condition remained healthy (D, E, F). Space was developed to incorporate
tooth number 13 into the arch (A, D, G, J). After dental alignment, the occlusion was corrected with orthognathic surgery and the gingival condition remained healthy
(J, K, L).
A
B
C
D
E
F
G
H
I
J
K
L
all the posterior teeth forward. In a non-extraction case, the
cleft side will be finished with class II relations; however, if
the lower bicuspids were extracted, the cleft-side occlusion
should finish with class I relations (see Fig. 25.1
). In cases
with a non-ideal bone graft outcome, the clinician may want
to move the canine forward into the grafted site to improve
bone morphology, rather than replacing the lateral incisor
with an osseointegrated fixture or a prosthesis that might
need additional bone grafting. In cases where the canine has
migrated forward into the lateral incisor position, and ideal
class I molar relations are present, the canine could be replaced
with an osseointegrated implant (see Fig. 25.27). Other con­
siderations include deciding on how to manage the missing
cleft-side maxillary incisor, as well as the shape, size, and
color of the canine, and the gingival contour in the area of the
cleft.3 If properly planned, both the prosthetic and orthodontic
options to manage the missing cleft-side lateral incisor can
provide outstanding results (Figs. 25.1, 25.15 & 25.27A
).
In situations where the alveolar cleft is too wide for con­
ventional bone grafting, the clinician may elect to surgically
shift the entire cleft-side posterior maxillary segment forward
and place the canine in the position of the missing lateral

605
Permanent dentition
Fig. 25.27  (A–I) Intraoral views of a patient with left unilateral cleft lip and palate, who was missing the cleft-side maxillary lateral incisor, had the maxillary canine
substituting the missing incisor, and had a retained primary canine (single arrow). Since ideal posterior occlusion was present, it was decided not to close the space with
orthodontics, but to replace the primary canine with an osseointegrated implant (double arrow). Note satisfactory occlusion and aesthetics after treatment. (J, K) Note in the
pretreatment panoramic radiograph (J) the presence of the permanent maxillary left canine in the position of the missing lateral incisor (arrow), and the retained primary
canine (dotted arrow). After treatment (K), note replacement of the primary canine with an osseointegrated implant (arrow).
A
B
C
D
E
F
G
H
I
J
K
incisor. This assures not only closure of the alveolar defect,
but also closure of the dental gap created by the missing
cleft-side maxillary lateral incisor.3,13,49 After bone grafting, it
is not uncommon to find that the cleft-side maxillary canine
has an unusual eruption path and is impacted. These teeth
need to be managed surgically by exposing them so the
orthodontist can incorporate them into the dental arch
(Fig. 25.28).
In some situations it is necessary to move teeth to close
extraction spaces or reposition teeth within the arch to obtain
better occlusal relations. In the past, intra-arch movements
were difficult as the orthodontist depended on the adjacent
teeth and patient cooperation using elastics or extraoral appli­
ances for anchorage control. With the introduction of BAS,
also known in orthodontics as temporary anchorage devices,
the orthodontist’s ability to achieve significant tooth move­
ments has been enhanced.50 BAS permit anteroposterior and
vertical control of a single tooth or group of teeth during
orthodontic treatment. The application of BAS is a simple
office procedure. After completing the orthodontic treatment,

606
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CHAPTER 25 • Orthodontics in cleft lip and palate management
A
B
C
D
E
F
Fig. 25.28  (A–F) Intraoral views of a patient with left unilateral cleft lip and palate that was congenitally missing the right maxillary lateral incisor and a peg-shaped left
one (arrow). The peg incisor was extracted, and the right maxillary canine was impacted, and needed surgical exposure so it could be incorporated into the arch. Note
satisfactory gingival and occlusal relations obtained after treatment.
the BAS are simply removed without negative sequelae
(Fig. 25.29).
Orthodontic management following the “developmental
approach”, as outlined above, allows the clinician to take
advantage of developmental and growth changes. In addi­
tion, it permits the patient and family to recognize the need
for distinct phases of orthodontic treatment, which also allows
for sufficient phases of rest between stages. This approach
assures patient and family acceptance, compliance, and coop­
eration with the treatment protocol.
Orthognathic surgery and distraction
procedures for the cleft patient
Skeletal and dental discrepancies between the maxilla
and mandible are not uncommon in cleft patients. These

607
Permanent dentition
G
H
(G, H) Panoramic radiographs before (G) and after (H) treatment. Note high position of the left maxillary canine (arrow) and incorporation into the
dental arch.
Fig. 25.28, cont’d
Fig. 25.29  (A–D) Intraoral views of a patient with unilateral right cleft lip and palate with anterior crossbite and severe maxillary and mandibular crowding. Maxillary lateral
incisors and mandibular first bicuspids were extracted. After the maxillary arch was consolidated, an anchorage screw (arrows) was used to assist with canine and incisor
retraction. Note space closure and correction of the anterior crossbite.
A
B
C
D
discrepancies can be in the sagittal, transverse, and vertical
planes. If the discrepancies are moderate to severe, they
are best managed with a combined surgical/orthodontic
approach. This approach results in substantial functional and
aesthetic improvements in the cleft patient (see Fig. 25.1
).
It is generally accepted that patients with orofacial clefts
have mandibles that are of normal size or slightly smaller.51
For this reason, in most patients with maxillary hypoplasia,
the surgeon may choose to perform sagittal correction with
surgery limited to the maxillary bone. In cases where there is

608
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CHAPTER 25 • Orthodontics in cleft lip and palate management
a skeletal open bite and marked mandibular deficiency or
asymmetry, a two-jaw approach must be undertaken. The
advantage of this surgical/orthodontic approach is that, with
one operation, the reconstructive team can provide the patient
with close to ideal occlusal relations, with markedly improved
function and aesthetics.
To assure success, close cooperation between the orthodon­
tist and surgeon is required. It is the responsibility of the
orthodontist to support the surgeon, so at the time of surgery,
adequate occlusal relationships can be obtained. This, in turn,
will add stability to the orthognathic procedure.
The planning for orthognathic surgery in the cleft patient
is no different to that done for the patient with a non-cleft
dentofacial deformity. This includes a detailed clinical exami­
nation and collection of pertinent records prior to orthodontic
treatment and again before surgery. All patients with palatal
clefts who undergo maxillary advancement surgery are at risk
for velopharyngeal insufficiency (VPI); therefore, evaluation
by the team speech and language pathologist is required
before and after surgery to discuss potential risks for and
postoperative correction of VPI if necessary. After all the
necessary records are obtained, the orthodontist will perform
a cephalometric analysis and prediction surgical tracing to
determine the required surgical movements. This can be done
by hand tracing the X-rays or by using computerized imaging
– virtual surgical planning (VSP) and cephalometric analysis.
With the introduction of VSP digital 3D software technology,
based on CT scans and more recently CBCT, a new approach
has been developed to assist surgeons and orthodontists in
the planning of craniomaxillofacial surgery.52–56 This approach
utilizes digital data from the scans, which in turn is managed
by specialized software to create a 3D virtual model of the
craniofacial skeleton. The desired surgical movements can be
performed digitally. Based on the digital data, a physical
model of the skull or the surgical splints can be constructed
through stereolithography. This approach obviates the use of
the traditional presurgical planning that included use of a face
bow and dental articulators to plan and do model surgery.
Although the traditional approach has provided satisfactory
outcomes, it can be inaccurate for complex movements
and requires a sophisticated degree of proficiency acquired
through experience. Delegation of this approach is not pos­
sible, and the surgeon and orthodontist need to spend signifi­
cant laboratory time to plan surgery and prepare the needed
surgical splints.
Significant research and technological developments have
permitted accuracy of VSP, especially the incorporation of
accurate digital dental models from plaster casts into the
maxillofacial model obtained through the CT and CBCT
scans.57–59 As VSP approaches become more familiar and
accessible to clinicians, the planning and construction of
surgical splints, surgical guides, and the execution of complex
maxillofacial surgery required by cleft patients should
improve and predictable and successful outcomes should be
routinely obtained (Figs. 25.30 & 25.31; Table 25.1). In addition
the clinician should be able to delegate significant aspects
of the planning and splint fabrication procedures.60,61 This
approach gives the clinician a close approximation of the
desired outcome, but they must be aware of the limited
knowledge on soft-tissue responses (lip, nose, and velopha­
ryngeal structures) relative to skeletal movement, especially
in cleft patients. Additional research on 3D responses of the
facial soft tissues after maxillo/mandibular surgery is still
needed. It is emphasized that it is the clinician and not the
computer that will make the final treatment and surgical deci­
sions. The 3D computerized technological advances of VSP
allow the clinician diagnostic evaluation in all three planes of
space, providing postsurgical evaluation that was not possible
before. These include changes in airway volume after maxil­
lary and mandibular surgery62–64 and volumetric bone changes
after alveolar bone grafting.65,66
Recently, however, there has been a resurgence of a “surgery
first, orthodontics later” approach.67,68 The desired approach,
especially for the cleft patient, is opposite – “orthodontics
first”, followed by surgery and finishing orthodontics. Before
Text continued on p. 613
Table 25.1  Values obtained from the virtual planning software representing the desired movements in three dimensions of the various
maxillary, mandibular, and dental structures
Point
Name
Anterior/Posterior
Left/Right
Up/Down
ANS
Anterior nasal spine
8.00 mm anterior
1.28 mm left
0.98 mm up
A
A point
7.53 mm anterior
1.09 mm left
1.30 mm up
ISU1
Midline of upper incisor
6.00 mm anterior
0.50 mm left
1.00 mm up
U3L
Upper left canine
6.12 mm anterior
0.54 mm left
1.55 mm up
U6L
Upper left anterior molar (mesiobuccal cusp)
6.19 mm anterior
0.56 mm left
1.92 mm up
U3R
Upper right canine
6.12 mm anterior
0.52 mm left
2.85 mm up
U6R
Upper right anterior molar (mesiobuccal cusp)
6.21 mm anterior
0.55 mm left
3.41 mm up
ISL1
Midline of lower incisor
2.94 mm posterior
4.53 mm right
3.72 mm up
l6L
Lower left anterior molar (mesiobuccal cusp)
1.03 mm posterior
2.15 mm right
0.80 mm up
L6R
Lower right anterior molar (mesiobuccal cusp)
5.11 mm posterior
2.30 mm right
3.72 mm up
B
B point
1.73 mm posterior
5.15 mm right
3.30 mm up
Pog
Pogonion
1.15 mm posterior
5.66 mm right
3.24 mm up
Note 6 mm advancement of the upper incisor and movement of pogonion to the right 5.66 mm.

609
Permanent dentition
A
B
C
D
E
F
G
H
I
J
K
L
Fig. 25.30  Pre-treatment (A–C) three-dimensional scans from a patient with repaired complete left unilateral cleft lip and palate with maxillary hypoplasia and left
mandibular asymmetry. A two-piece maxillary Le Fort I advancement (green), with simultaneous bilateral sagittal split osteotomies (blue) for correction of the asymmetry
were planned (D–F) for the patient. (G–L) Orthognathic Positioning System. Virtual design of occlusal based removable drilling guides to place reference holes above the
osteotomy line (G–I). The guides will be manufactured with hard resin through stereolithography. The round openings on the guides will be used to place a metal drill guide
for exact placement of the landmarks. Using the post maxillary advancement virtual plan, the final positioning guides (J–L) are designed and manufactured as indicated
above. These guides are longer than the drilling guides as they are made with the maxilla in the advanced desired new position. The smaller perforations on the final guides
are used to locate the reference landmarks to assure exact position of the advancement maxilla and also for temporary fixation with bone screws. Once secured, medial rigid
fixation is applied with plates and screws, the guides are removed, and the maxillary buttresses are fixated.
Continued

610
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
M
N
O
P
Q
R
S
T
U
(M) Location of the landmarks on the maxillary buttresses where the bone is thick enough to support screw fixation. Note values for the bone thickness
on the intended reference perforations or landmarks. Facial (N–P) and intraoral (Q–U) photographs of a 16-year-old female with a repaired left complete unilateral cleft lip
and palate after initial orthodontics and alveolar bone graft surgery. Note retrusive upper lip, prominent lower lip, and mandibular skeletal asymmetry to the left. Intraorally,
she had anterior and left crossbites, anterior open bite, teeth #5 and 10 were missing, the mandibular dental midline was to the left of the upper one and there was mild
lower crowding.
Fig. 25.30, cont’d

611
Permanent dentition
A
B
C
D
E
F
G
H
W
V
The panoramic radiograph (V) confirms missing teeth #5 and
10 and impacted teeth #17 & 32. The cephalometric radiograph (W) reveals
maxillary hypoplasia and mild mandibular prognathism.
Fig. 25.30, cont’d
Fig. 25.31  (A–C) Facial photographs prior to surgery.
(D–H) Intraoral views after orthodontic alignment of
both arches and prior to surgery. Tooth #11
substitutes the missing left lateral incisor (#10). Note
decompensation of the dentition with worsening of the
anterior crossbite. The arches are aligned and
coordinated; the mandibular midline is to the left of
the upper one.
Continued

612
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
I
J
K
L
M
N
O
(I) Cephalometric tracing superimposed on the presurgical cephalometric radiograph. (J) Prediction tracing demonstrating the planned maxillary
advancement, mandibular setback, and genioplasty. Computer generated numbers are seen to the right. (K) Note similarity to those obtained during the virtual surgical
planning. (L) Computer morphing of the lateral facial photograph demonstrating the predicted improved profile facial change. Facial (M–O) and intraoral (P–T) photographs
after surgery. Note improvement of the upper lip retrusion and mandibular skeletal asymmetry. The intraoral photographs demonstrate excellent occlusal relations with
correction of the anterior and left crossbites. Clinical results are similar to the virtual and cephalometric plans.
Fig. 25.31, cont’d

613
Permanent dentition
P
Q
R
S
T
Fig. 25.31, cont’d
surgery, the orthodontist must position all teeth within their
supporting basal bones with the maxillary incisors in an ideal
position relative to the palatal plane and the mandibular inci­
sors in ideal axial inclination relative to the mandibular plane.
Both arches need to be properly coordinated to allow for ideal
occlusal interdigitation at the time of surgery. In addition,
the orthodontist must create interdental spaces to facilitate
instrumentation, if interdental osteotomies are anticipated.
The orthodontic appliance is used during the period of
intermaxillary fixation and immediately after surgery for
postsurgical elastic therapy (Fig. 25.32
) and detailing of the
occlusion. Close cooperation between the orthodontist and
surgeon during the planning and initial orthodontic treat­
ment stages should yield favorable occlusal, functional, and
aesthetic outcomes (see Figs. 25.1 & 25.32
).
In patients in whom the maxillary deficiency is severe and
where there is substantial scarring or existing pharyngeal
flaps, conventional orthognathic procedures are not reliable
due to the inherent lack of stability and high relapse tenden­
cies.69,70 When performing conventional procedures in young
patients with severe maxillary hypoplasia, one must wait
until adolescence for surgical correction as these techniques
rely on rigid fixation that requires substantial bone for place­
ment of the hardware. Further, unerupted tooth buds might
be injured during the application of rigid fixation plates. For
young patients with severe maxillary deficiency, we have
utilized distraction osteogenesis with a rigid external distrac­
tion (RED) device, and internal devices for patients with mild
to moderate deficiencies. The technique of maxillary distrac­
tion utilizing a RED device has been previously described71–75
and consists of five steps: (1) the fabrication of an intraoral
splint that is used to deliver the distraction forces to the
maxilla via the teeth; (2) a complete high Le Fort I osteotomy
with septal and pterygomaxillary disjunction; (3) the place­
ment of a cranial halo with an external adjustable distraction
screw system; (4) distraction; and (5) rigid and removable
retention, as previously presented.
This technique has been applied to young children as
well as adolescents and adults, with excellent functional and
aesthetic results (Figs. 25.33 & 25.34). The stability of the
procedure has been remarkable and superior to that reported
for conventional orthognathic surgical approaches.73,75–78 The
soft-tissue changes have also been superior to those reported
when conventional orthognathic surgical techniques are used
in cleft patients.79,80 The velopharyngeal mechanism of these
patients is minimally affected, especially for those patients
having pharyngeal flaps who report improved articulation
and resonance. Patients without pharyngeal flaps requiring
major advancements can have postdistraction velopharyn­
geal incompetence requiring treatment with a pharyngeal
flap or another type of pharyngoplasty.81,82 To date, we have
not seen negative effects on dental development; although,
when performed in children under 6 years of age, we have
noted, on occasion, rotation of a permanent second molar
tooth bud as a result of increases in posterior arch length or
surgical trauma.
Internal devices have been used in patients with less severe
maxillary hypoplasia. The device used by the authors is a
hybrid device (skeletal and dental anchorage) with the main
advantage of not requiring a second operation for its removal.
The device has been used successfully, with excellent func­
tional and aesthetic outcomes83 (Figs. 25.35–25.37
).
Figs. 25.35–25.37 appear online only.
Maxillary distraction now offers a solution for the difficult
cleft maxillary hypoplasia deformity. In addition, the tech­
nique has been expanded to other patients with syndromic

613.e1
Growth and orthodontic treatment
A
B
C
Fig. 25.35  Intraoperative view (A) of the placement of a hybrid (bone–dental)
internal maxillary distractor for Le Fort I maxillary advancement. Intraoral view (B) of
the activating arm after incision closure. Note the horizontal arm of the distractor is
wired through an intraoral metal splint (arrows). Cephalometric (C) and panoramic
(D) radiographs demonstrating the buttress plates, adjustable and removable vertical
stem, and horizontal distractor arm.
D

613.e2
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
Fig. 25.36  After distraction and
consolidation the device is removed in the
office setting; the horizontal arms are
unwired and removed from the vertical
stems (A, B). The vertical stem is
unscrewed from the buttress plate and
removed. The small vestibular wound is left
to close spontaneously (C, D).
A
B
C
D

613.e3
Growth and orthodontic treatment
A
B
C
D
E
F
G
H
I
J
K
L
Fig. 25.37  Before (A–C) and after (D–E) facial photographs of a patient with right unilateral cleft lip and palate and moderate maxillary hypoplasia who underwent Le Fort I
maxillary advancement utilizing an internal adjustable and removable distraction device. Note improvement of facial convexity and lip/nose relations after treatment. Intraoral
views before (G–I) and after (J–L) treatment. Note anterior crossbite and class III relations before treatment. The maxillary canines were used to replace the missing lateral
incisors; she was completed with positive overjet and overbite and class II molar relations.
Continued

613.e4
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
M
N
O
P
Cephalometric and panoramic radiographs before (M, O) and after (N, P) treatment. Note moderate maxillary hypoplasia and concave profile before
treatment as well as the still-erupting second maxillary molars. After treatment the maxilla was advanced, improving the skeletal and soft-tissue profile as well as anterior
dental relations. Note continued eruption of maxillary second molars (horizontal arrow) and the buttress plates that remain after the distractor was removed (vertical arrow)
after treatment.
Fig. 25.37, cont’d

614
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
A
B
C
D
E
F
G
H
I
Fig. 25.32  Intraoral views of a patient with right unilateral cleft lip and palate with missing maxillary right lateral incisor and anterior crossbite (A–C). After alveolar bone
grafting and orthodontic alignment (D–F), the patient underwent maxillary advancement with midline correction (G–I). Note use of elastics to the orthodontic appliance for
fixation and occlusal settling after surgery. After treatment, satisfactory occlusal relations were obtained. Note substitution of the missing right maxillary lateral incisor with
the canine, with right class II molar relations and left class I molar and canine relations (J–L).
J
K
L
conditions, such as Apert and Crouzon syndromes, and
traumatic deformities.
Growth and orthodontic treatment
It is imperative to recognize that abnormal facial growth
will present an added challenge to the reconstructive team.
It is understood that cleft patients do have different facial
growth patterns than those seen in non-cleft individuals.
However, cleft patients have significant growth potential. If
this potential is not negatively affected by the reconstructive
procedures required by the patient, it is likely that a favor­
able outcome will be obtained. Orthodontic treatment will be
simplified if minimal growth disturbances affect the patient.
Simplification and shortening of orthodontic treatment, which
is usually the longest therapeutic intervention for many
cleft patients, are desired, as this will decrease the burden
of care (e.g., patient, family, provider, public health system,
society).
Cleft teams should strive to obtain optimal outcomes by
critically assessing their protocols and incorporating proven

615
Conclusion
A
B
Fig. 25.33  Views of the intraoral splint with removable hooks used for maxillary and midface distraction with rigid external distraction. Note the square tubes (solid arrows)
and retention face mask hooks (broken arrow) (A). Occlusal view demonstrating labial and palatal bars soldered to the first molar bands and position of square tubes
(arrows) (B). At surgery, bone anchorage screws are placed and suspension wires are dropped to enhance anterior stability of the splint (arrows) (C). Extraoral hooks with
traction eyelets inserted through the square tubes of the splint (broken arrows) (D).
C
D
strategies to manage their patients. It is accepted that surgery
will likely create significant scarring in the infant maxilla,
resulting in growth attenuation. Careful attention should be
given to those protocols that minimize scarring in the anterior
maxilla (i.e., delaying alveolar bone grafting and minimiz­
ing palatal scarring by avoiding damage to the maxillary
body).84,85 This, in turn, will result in less need for extended
and complex orthodontic procedures. Finally, it should be
emphasized that the care of patients with orofacial clefts
does not end in adolescence; it will continue through the
life of the individual. As patients age, they will undergo the
expected soft- and hard-tissue facial changes seen in the non-
cleft population. In addition, they may be more susceptible
to unfavorable changes due to previous surgeries and the
resulting scarring. The maxillary dentition, adjacent to the
cleft, is likely more susceptible to periodontal issues due
to dental abnormalities (short roots, abnormally shaped
crowns), lower than normal bone levels after alveolar bone
grafting, previous orthodontic treatment, dental restorations,
and issues related to deficient dental hygiene (usually during
the early teen years). The cleft team should make every effort
to follow patients long-term, in order to advise and remain
as a resource, providing additional treatment as it becomes
necessary.
Conclusion
The important contribution of the orthodontist to the com­
prehensive surgical orthodontic management of the cleft
patient is illustrated herein. The role of the orthodontist is to
support the surgeon with all aspects of craniofacial growth,
dental development, occlusion, and treatment planning
so that ideal outcomes can be obtained. With the addition
of nasal alveolar molding as well as maxillary distraction
osteogenesis, the traditional protocols for cleft management
have been expanded. In addition, the incorporation of new
technological advancements in orthodontics, such as highly
flexible orthodontic arch wires, self-ligating orthodontic
appliances, BAS, and accessibility to new virtual surgical plan­
ning technology and manufacturing, facilitates the required
treatment interventions. It is hoped that these innovations
will provide clinicians with new strategies for the difficult
management of the cleft patient and will provide the patient
with outstanding outcomes. The treatment plan of the patient
should be developed around the anatomical, functional,
and developmental needs of the patient. Close cooperation
between the surgeon and orthodontist is imperative for a
successful outcome.

616
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
A
B
C
D
E
F
G
H
I
J
K
L
Fig. 25.34  (A–F) Facial photographs of a patient with bilateral cleft lip and palate with severe maxillary deficiency who underwent a high Le Fort I osteotomy and
advancement with rigid external distraction (A,D). Before (B,E) and after (C,F) distraction frontal and profile views. Note dramatic facial balance improvement after
treatment. Intraoral views before (G–I) and after (J–L) distraction. Note severe class III relations before treatment and restoration to a functional and aesthetic occlusion after
treatment.

617
Conclusion
Anterior crossbite
Transitional dentition
Fig. 25.1 (A–I) Facial and (J–R) intraoral photographs; (S–U) panoramic and
(V–X) lateral cephalometric radiographs of a patient with unilateral cleft lip and
palate. The patient underwent lip and palate surgery in infancy. He had an
alveolar bone graft in the transitional dentition. He had a diminutive tooth
number 7 that was extracted and substituted with number 6. In late childhood,
maxillary deficiency was noted and persisted until adolescence. He had
orthodontic preparation of the dentition and underwent surgical maxillary
advancement with rigid fixation. His treatment was successful, with satisfactory
facial, occlusal, and skeletal outcomes.
Fig. 25.2 Dental cast (A) of an infant with unilateral cleft lip utilized to fabricate
a palatal plate (B) to which a stainless-steel wire (C) is attached to fabricate the
nasal stent required for molding the nasal structures.
Fig. 25.3 The wire to fabricate the nasal stent is left long (A), measured relative
to the height of the nose, and cut and bent, leaving an “adjustment loop” (lower
arrow) and a terminal loop (upper arrow) to attach the nasal conformer part of
the stent (B). The end of the wire is covered by hard acrylic and lined with soft
acrylic to fabricate the nasal stent (arrows) (C). Patient without (D) and with (E)
nasoalveolar molding plate in place.
Fig. 25.4 Facial photographs of a patient with unilateral cleft lip and palate
before (A), after nasoalveolar molding and before lip surgery, frontal view (B)
and worm’s-eye view (C). Intraoral views before (D) and after (E) nasoalveolar
molding. Note alveolar and palatal cleft narrowing and improved nasal form after
nasoalveolar molding and prior to lip surgery. Frontal facial photograph after
nasoalveolar molding and lip surgery (F).
Fig. 25.5 Patient with unilateral cleft lip and palate undergoing nasoalveolar
molding (A) and with facial taping (B). Note rounding of the alar cartilage
around the nasal stent.
Fig. 25.6 After nasoalveolar molding and lip surgery a nasal stent is inserted
(A) and secured with tape (B). Note base tapes adhering to the cheeks (A),
used to secure the nasal stent tape and to prevent skin irritation during frequent
tape replacement.
Fig. 25.7 (A) Frontal, (B) profile, and (C) intraoral photographs of a patient
with bilateral cleft lip and palate with protrusive and deviated premaxilla. She
underwent premaxillary repositioning with an intraoral plate (D) with an anterior
elastomeric chain (E). (F, G) Frontal, (H) profile, and (I) intraoral photographs
after premaxillary repositioning and prior to nasal molding. Note reduction of
premaxillary asymmetry and protrusion as well as improved nasal form.
Fig. 25.8 After initial premaxillary repositioning, patient with bilateral cleft and
palate undergoing nasal molding. Note two nasal stents added to the plate with
an anterior elastomeric chain (A, B). While the elastomeric chain is holding the
premaxilla and prolabium down and back, the nasal stents elevate the nasal tip,
repositioning the nasal domes towards the midline and elongating the columella
(C–E).
Fig. 25.9 Frontal, profile, and nasal photographs of a patient with bilateral cleft
lip and palate who underwent presurgical nasoalveolar molding treatment and
primary lip repair. Comparison of before (A–C) and after (D–F) nasoalveolar
molding photographs illustrate reduction of premaxillary asymmetry and
protrusion as well as improvement of nasal asymmetry. A satisfactory lip and
nasal repair was obtained soon after lip surgery (G–I). Four years after surgery
(J–L), the patient maintains excellent lip line, nose/lip relations, nasal
symmetry, and projection.
Fig. 25.10 Long-term follow-up of a patient with unilateral cleft lip and palate
treated with presurgical nasoalveolar molding, and only primary lip and palate
repair and alveolar bone grafting. Close-up photos of the nose before (A) and
after (B) nasoalveolar molding, and feeding with the nasoalveolar molding
prosthesis in place (C). Facial photos before treatment (D), postsurgery at 2
(E), 9 (F), and 16 (G) years of age. Note satisfactory outcome with nice lip line
and stable nasal symmetry.
Fig. 25.11 Patient with unilateral cleft lip and palate in the transitional dentition
prior to orthodontic preparation for alveolar bone grafting (A–C), after
orthodontic treatment (D–F), and after bone graft (G–I). Note alignment of the
dental arch with a simple segmental edgewise orthodontic appliance. (J–L)
Occlusal views at similar stages. Note missing lateral incisor and retained
primary canine in the cleft area (arrow) (J). This tooth was extracted prior to
surgery. Note aligned arch prior to surgery (K). After surgery, the permanent
canine erupted through the bone-grafted area (arrow) (L). (M–O) Panoramic
radiographs at similar stages: note in the pretreatment radiographs (M,N)
complete apical root development of the maxillary incisors (single arrow),
Bonus content for this chapter can be found online at

M
N
Before treatment (M) note vertical and horizontal maxillary hypoplasia. After treatment (N), the amount of advancement is indicated by the horizontal
arrow. The vertical arrows indicate the newly formed bone. Note absence of any fixation hardware, correction of preoperative open bite tendency, as well as anterior dental
relations.
Fig. 25.34, cont’d

618
SECTION I
CHAPTER 25 • Orthodontics in cleft lip and palate management
retained primary canine and missing lateral incisor (dotted arrow), and unerupted
maxillary left canine (double arrows). After orthodontics and bone grafting (O),
note intact maxillary incisor root apices (single arrow) and maxillary left canine
erupting through the bone graft (double arrows). (P) After treatment an interim
prosthesis was given to the patient replacing the missing lateral incisor (arrow).
Fig. 25.12 (A–D) Maxillary arch expansion and dental alignment in a unilateral
cleft lip and palate patient with severe scarring and collapse. Treatment was
achieved in a slow fashion with the use of highly flexible wires and a
self-ligating bracket.
Fig. 25.25 (A) Panoramic radiograph of a 6-year-old female patient with
complete left unilateral cleft lip and palate in the early transitional dentition
stage. She is missing the second right maxillary second bicuspid and has a peg
cleft-side permanent maxillary lateral incisor. The cleft-side primary canine had
a stainless steel crown and had signs of early root resorption compared to the
contralateral canine. This tooth was scheduled for extraction. (B–E) Frontal
intraoral photographs. (B) Pre-treatment view. (C) During expansion and
maxillary arch dental alignment. (D) After arch alignment and eruption of the
peg-shaped lateral incisor and prior to the bone graft. (E) Orthodontic
movement of the peg-shaped lateral incisor through the bone graft. After
complete mesialization the patient was placed in retention to allow for eruption
of the permanent dentition and finalize orthodontic treatment. (F) A year later
treatment was re-initiated, the peg-shaped lateral incisor extracted, and the
cleft-side permanent canine moved into the position of the lateral incisor. All
posterior teeth in that quadrant were moved forward to consolidate the arch.
Note adequate gingival tissues and ideal occlusal relations. (G–J) Occlusal
view of the maxillary arch during various stages of treatment. (G) In early
transitional dentition prior to treatment. (H) Maxillary expander and orthodontic
brackets to align the arch and dentition prior to bone graft surgery. Note
eruption of the peg-shaped maxillary cleft-side lateral incisor after extraction of
the primary canine with stainless steel crown. (I) After the alveolar bone graft
the cleft-side lateral incisor has been moved through the graft next to the
cleft-side maxillary central incisor. Note thickness of the alveolar ridge and
transpalatal bar used for retention after expansion. (J) Finishing stages of
orthodontic treatment after extraction of the peg-shaped maxillary cleft-side
lateral incisor and incorporation of the cleft-side maxillary canine in its position.
The maxillary arch is well aligned and spaces have been consolidated.
Fig. 25.35 Intraoperative view (A) of the placement of a hybrid (bone–dental)
internal maxillary distractor for Le Fort I maxillary advancement. Intraoral view
(B) of the activating arm after incision closure. Note the horizontal arm of the
distractor is wired through an intraoral metal splint (arrows). Cephalometric (C)
and panoramic (D) radiographs demonstrating the buttress plates, adjustable
and removable vertical stem, and horizontal distractor arm.
Fig. 25.36 After distraction and consolidation the device is removed in the
office setting; the horizontal arms are unwired and removed from the vertical
stems (A, B). The vertical stem is unscrewed from the buttress plate and
removed. The small vestibular wound is left to close spontaneously (C, D).
Fig. 25.37 Before (A–C) and after (D–E) facial photographs of a patient with
right unilateral cleft lip and palate and moderate maxillary hypoplasia who
underwent Le Fort I maxillary advancement utilizing an internal adjustable and
removable distraction device. Note improvement of facial convexity and lip/nose
relations after treatment. Intraoral views before (G–I) and after (J–L) treatment.
Note anterior crossbite and class III relations before treatment. The maxillary
canines were used to replace the missing lateral incisors; she was completed
with positive overjet and overbite and class II molar relations. Cephalometric
and panoramic radiographs before (M, O) and after (N, P) treatment. Note
moderate maxillary hypoplasia and concave profile before treatment as well as
the still-erupting second maxillary molars. After treatment the maxilla was
advanced, improving the skeletal and soft-tissue profile as well as anterior
dental relations. Note continued eruption of maxillary second molars (horizontal
arrow) and the buttress plates that remain after the distractor was removed
(vertical arrow) after treatment.
8. Grayson BH, Santiago PE, Brecht LE, et al. Presurgical nasoalveolar
molding in infants with cleft lip and palate. Cleft Palate Craniofac J.
1999;36:486–498. This article introduces the now-widespread concept of
presurgical nasoalveolar molding. The authors conclude that nasoalveolar
molding eliminates the need for surgical columella reconstruction.
69. Posnick JC, Dagys AP. Skeletal stability and relapse patterns after
Le Fort I maxillary osteotomy fixed with miniplates: the unilateral
cleft lip and palate deformity. Plast Reconstr Surg. 1994;94:924–932.
This study assesses relapse rates in 35 consecutive patients undergoing Le
Fort I osteotomy with miniplate fixation and autogenous bone grafting.
The authors found that miniplates do not prevent relapse in this
population.
73. Polley JW, Figueroa AA. Rigid external distraction: its application in
cleft maxillary deformities. Plast Reconstr Surg. 1998;102:1360–1372.
The authors present the use of rigid external distraction to correct
maxillary hypoplasia in patients with facial clefts. Dramatic improvements
in skeletal anatomy and soft-tissue deficiencies were observed.
75. Paresi R Jr, Felsten L, Shoukas J, et al. Maxillary distraction
osteogenesis. In: Losee J, Kirschner RE, eds. Comprehensive Cleft
Care. New York: McGraw Hill; 2009:956–968. This chapter offers a
useful review of maxillary distraction in the context of orofacial clefting.
Cephalometric evaluation is emphasized.
82. Guyette TW, Polley JW, Figueroa A, et al. Changes in speech
following maxillary distraction osteogenesis. Cleft Palate Craniofac J.
2001;38:199–205. Articulation and velopharyngeal function were assessed
before and after maxillary distraction. Metrics included hyper/
hyponasality, velopharyngeal passage dimensions, and articulation error.
Access the complete reference list online at

618.e1
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