Orthodontic treatment for patients with clefts

Clin Plastic Surg 31 (2004) 271–290

Orthodontic treatment for patients with clefts

Carla A. Evans, DDS, DMSc

Department of Orthodontics, The University of Illinois at Chicago, 801 South Paulina Street, MC 841,

Chicago, IL 60612-7211, USA

It has become increasingly evident that treatment and prosthetic replacement of missing teeth, but ma-

of oral clefts has many limitations and leaves more

than a scar on the lip. Adults who have treated clefts

often have characteristics that are visible at a distance

and give clues about the nature of the original con-

genital anomaly, such as shape of face, abnormal

animation of face, nasal asymmetry, unsightly teeth,

unclear and nasal speech, and chewing difficulties.

Just getting on the bus to go to work may be stressful

for individuals with treated clefts because of the

public’s responses to people with facial differences.

Marcusson [1] investigated quality of life, satisfaction

with treatment, prevalence of temporomandibular

disorders, psychosocial distress, and occlusal stability

in 68 Swedish adult patients with treated cleft lip/

palate for whom comprehensive treatment was con-

ducted under the national health system and for whom

follow-up records were available. Despite being so-

cially well adjusted and having relatively normal daily

lives, the patients with treated cleft lip/palate were

generally dissatisfied with their nose, lips, mouth,

profile, and overall facial appearance and reported

that their well-being and social lives were affected by

their condition. In addition, the occlusal result was

significantly unstable, irrespective of the type of

retention, but was not linked with temporomandibular

joint disturbances.

Fig. 1 shows an example of residual problems in

an adult patient with bilateral cleft lip and palate who

was treated in the United States. The patient had lip

and palate closure, columella lengthening, an Abbe

flap, orthognathic surgery to set back the mandible,

0094-1298/04/$ – see front matter D 2004 Elsevier Inc. All right

doi:10.1016/S0094-1298(03)00125-1

E-mail address: [email protected]

jor functional, anatomic, and aesthetic shortcomings

remained. The patient’s lips were tight and didn’t

move well, her face was very flat with both maxillary

and mandibular retrusion, the premaxilla had not

been grafted and the mobility caused the dental

bridge to loosen, the dental occlusion was inefficient

for chewing, the oronasal fistulae allowed food and

secretions to move between the mouth and the nasal

passages, the palate was highly scarred, and the muco-

gingival condition was poor because the multiple

tight labial frenums caused gingival recession. Each

clinician individually had rendered state-of-the-art

treatment but had not worked with the others as a

team. This example adds to the evidence that treat-

ment of oral clefts is much more complex than just

closing the cleft space because so much is at stake in

terms of growth and function.

Because clinicians have reviewed treatment out-

comes in recent times, their recommendations regard-

ing therapy have become more focused on specific

problems [2–5], such as ways to promote normal

growth, advance the maxilla rather than set back the

mandible, retain as many natural teeth as possible,

and use implants for tooth replacement and as an-

chorage for dentofacial orthopedics. It is useful to

study the natural history of individuals who have

untreated clefts and compare this with normal indi-

viduals to understand the effects of treatment. For

example, the growth potential of the untreated cleft

maxilla was studied in 30 untreated nonsyndromic

Indian adults who had complete unilateral cleft lip

and palate [6], with the observation that the size and

position of the cleft maxilla compared favorably in

comparison to a control group of 30 non-cleft Indian

individuals who had a normal occlusion. Several texts

[7–14] provide basic information about clefts and

s reserved.

Fig. 1. (A–D) Problems remaining after a poorly coordinated treatment program include a retruded maxilla and mandible; tight

lips; mucogingival problems, with gingival recession; open oronasal fistulae; a mobile premaxilla; inefficient chewing; and a

loose dental bridge.

C.A. Evans / Clin Plastic Surg 31 (2004) 271–290272

their treatment and show that conventional treatment

has many side effects. Thus, growth and function

must be considered in addition to short-term aes-

thetics in choosing a course of treatment that will lead

to long-term success.

Because of their education and experience, ortho-

dontists have much to contribute to the treatment

team in terms of knowledge of growth and develop-

ment and coordination of treatment. In addition to

providing orthodontic appliances to accomplish spe-

cific treatment objectives, orthodontists should par-

ticipate in long-term observations and analysis of

treatment outcomes. This article reviews various roles

of the orthodontist, namely recordkeeping, planning

and delivering treatment, and monitoring growth

and development.

Recordkeeping

Two important monographs available from the

American Cleft Palate-Craniofacial Association

[15,16] summarize current guidelines for providing

coordinated and comprehensive care to patients with

oral clefts. Topics include composition of the treat-

ment team, the acquisition of diagnostic records at

appropriate intervals, and the need for longitudinal

assessment. Typical orthodontic records include the

following: facial moulages; two- and three-di-

mensional facial and intraoral imaging; dental study

models in occlusion; measurements of height and

weight; and various radiographs, such as periapical,

panoramic, cephalometric, hand-wrist, and temporo-

mandibular joint films. Establishing the protocol for

C.A. Evans / Clin Plastic Su

collecting diagnostic information about each type of

patient should be based on sound orthodontic con-

cepts and is a team decision.

Treatment

Neonates and infants

Orthopedic repositioning of the alveolar segments

or nasoalveolar molding preceed lip and palatal

surgery [17,18]. Surgeons who advocate presurgical

orthopedics emphasize that surgical closure is easier

after orthopedics because the dental arches and lips

are in better alignment than at birth, the cleft may

be smaller, and better symmetry is achieved. It is

not known how long the benefits are maintained af-

ter surgical correction or whether normal growth is

stimulated or better long-term outcomes are achieved.

The short-term benefit is important, however, given

the significance of the initial operations to the long-

term success of treatment.

Early bone grafting of the cleft alveolus [11,

19,20] is more controversial in that some methods

may be associated with midface growth inhibition.

Proponents argue, however, that the graft gives sta-

bility to the arches, prevents collapse of the alveolar

segments, guides tooth eruption, allows orthodontic

tooth movement, reduces the occurrence of oronasal

fistulae, and reduces the need for future surgical

procedures in that area. Critics note that the eventual

bridge of bone joining the alveolar segments may not

have sufficient volume to bear dental implants or

support the alar base; secondary bone grafting may

still be necessary.

Sometimes malpositioned or extra teeth are re-

moved at the time that the palate is closed and may be

erroneously assumed later to be congenitally absent.

The timing of palatal closure varies from one cleft

center to another.

Toddlers and preschool children

Oral health care for children with a cleft begins

with educating the childrens’ parents about dental

development, the importance of good oral hygiene

and a healthy diet, disturbances that may result from

the cleft, and how to avoid nursing-bottle caries.

Visits to the pediatric dentist begin at approximately

age 2 to ensure caries control; assess toothbrushing,

oral hygiene, and diet; evaluate oral habits; and

monitor tooth development and eruption. Sometimes

dental extractions are necessary.

Elementary school age

Secondary bone grafting has become a well-ac-

cepted procedure [21–28]. Orthodontists align the

dental arches and teeth in preparation for bone graft-

ing. If the procedure is performed between age 6 and

10, depending on maturation of teeth, unerupted per-

manent teeth may erupt into the graft and be pre-

served. Recent patient series [26–28] showed that

success was greatest when the graft was placed before

eruption of the permanent canines. Most of the per-

manent canines erupted spontaneously. Increased ex-

perience of the surgeon enhanced the rate of success

as measured by bone height, gingival health, and

space closure by orthodontic means [26].

Arch alignment before secondary bone grafting

can be obtained using various expanders. In young

children with unilateral clefts, a quadhelix (Figs. 2

and 3) achieves the desired change. In bilateral clefts,

bilateral symmetric expansion is usually needed and a

traditional expansion screw is effective (Fig. 4). The

unerupted teeth migrate quickly through the bone

graft if the graft is not placed too early or too late,

similar to Fanning’s [29] observations that the erup-

tion of premolars can be accelerated when their cor-

responding primary molars were extracted. In Fig. 2,

the permanent canine traveled through the graft

past the lateral incisor and emerged unexpectedly

next to the central incisor.

A trend has emerged to place alveolar bone grafts

at a younger age when suitable lateral incisors are

present [30–32]. Fig. 3 shows a highly successful

outcome. As seen in the occlusal radiograph, the

lateral incisor formed distal to the cleft. After moving

the lateral incisor through the graft into the dental

arch and building up the incisors with restorative

composite, a full, natural dentition was present in

this child who had a complete unilateral cleft lip and

palate. Grafting only restores the alveolar process,

however; no graft is placed in the palate and bone

does not form there. In a patient who lacked lateral

incisors (see Fig. 4), plastic teeth were added to an

orthodontic retainer. Afterwards, a bonded bridge was

used to maintain the result until growth was com-

pleted and either a fixed bridge or dental implants

could be placed. When preserving teeth is not an

objective or when lateral incisors are not present,

secondary bone grafting can be done later. Successful

grafting and subsequent tooth movement also have

been reported with other methods [33,34].

In children with a cleft who have mild midface

retrusion, orthopedic maxillary protraction may be

used [35–39], but palatal scarring and tightness of

the lips are likely to reduce the amount of skeletal

rg 31 (2004) 271–290 273

Fig. 2. Management of a collapsed lesser segment in a patient with a unilateral cleft lip and palate. (A–D) Initial malocclusion

and maxillary expansion, with a quadhelix orthodontic appliance. (E) Removal of an erupted supernumerary incisor in the distal

segment, followed by alveolar bone grafting. (F) The remarkable path of eruption of the canine to a position between the central

and lateral incisors.


Fig. 3. A classic example of a successful secondary bone graft with preservation of the lateral incisor. (A, B) Alignment of the

dental arches after removal of the orthodontic expansion appliance and alveolar bone grafting. (C) Radiograph showing the width

of the bone bridge and position of the lateral incisor. (D, E, F) Arrangement of the teeth after active orthodontic tooth movement,

before and after prosthetic restoration of normal incisor shapes and sizes.

C.A. Evans / Clin Plastic Surg 31 (2004) 271–290 275

maxillary advancement achieved as compared with

treatment of children without clefts. Even in normal

children with malocclusion, maxillary protraction has

limited effectiveness. In addition, because the devices

are usually attached to teeth, a moderate amount of

dental advancement is observed. It has been demon-

strated that protraction using implants is possible [40]

and that this method avoids the unfavorable dental

changes. In the future, new protraction devices may

use short-duration dynamic forces rather than continu-

ous forces as they are currently delivered, because

current research on the mechanobiology of sutures is

exploring the response of cells to oscillating mechani-

cal signals [41].

Fig. 4. Management of a patient with a bilateral cleft. (A, B) Expansion with a tooth-borne (hyrax) expander and alveolar bone

grafting. (C, D) A removable orthodontic retainer with plastic teeth. (E, F) A bonded bridge that involves little preparation of the

teeth and doesn’t interfere with tooth eruption or growth.


Adolescents and adults

Surgical assistance may be valuable in the treat-

ment of the protruding premaxilla in adolescent and

adult patients who have bilateral clefts [42]. In a

child, the premaxilla may still be mobile (Fig. 5).

After expansion, an extrusion orthodontic archwire

may be used to guide the premaxilla into the proper

position for secondary bone grafting. In a more ma-

ture individual who has more rigid skeletal attach-

ments (Fig. 6), palatal expansion was facilitated by

zygomatic buttress osteotomies [43,44], followed by

a premaxillary osteotomy [45,46] at the time of

alveolar bone grafting. In individuals who have clefts,

the zygomatic buttresses become very stiff to resist

masticatory force; they also resist attempts at palatal


expansion with orthodontic appliances. Surgical re-

leasing osteotomies improve the stability of expan-

sion and facilitate rotational movements.

In adolescent or adult patients with clefts who

need orthognathic repositioning of the jaw, emphasis

is placed on advancing the maxilla rather than setting

back the mandible [47–50]. Before satisfactory sur-

gical methods were available to advance the maxilla

Fig. 5. Management of a protrusive and mobile premaxilla. (A)

incisors in infraclusion. (B, C) Pretreatment dental occlusion with

lip. (D, E) Treatment photos showing an expander that causes

helix to improve archform and vertical guidance of the premaxilla

bone grafting.

sufficiently, compromise treatment plans sometimes

involved setting back normal mandibles to resolve

negative overjet, jeopardizing facial appearance and,

potentially, breathing.

In mature patients who will have orthognathic

surgery, it may be necessary to undo previous ortho-

dontic treatment. For example, one patient who had

many years of orthodontic treatment to improve her

Pretreatment cephalometric radiograph showing retroclined

maxillary incisors in the bulging premaxilla just under the

anterior expansion. (F) Continued expansion with a quad-

with an extrusion arch. (G, H) Anterior views after alveolar

Fig. 5 (continued).


malocclusion was dissastisfied with her cleft appear-

ance (Fig. 7). First, additional orthodontic treatment

was performed to decompensate the teeth and retract

the maxillary anterior teeth into extraction spaces to

permit maxillary advancement. The nasal changes

Fig. 6. Management of a protrusive maxilla and transverse max

dental occlusion. (C, D) After surgically assisted (buttress osteotom

of the premaxilla, as shown in the diagram.

occurred as a consequence of the Le Fort I advance-

ment; no other nasal surgery was performed.

Surgical intervention to mobilize posterior seg-

ments may be warranted to decrease the size of a

fistula or advance a segment to minimize prosthetic

illary deficiency in a mature patient. (A, B) Pretreatment

ies) maxillary expansion followed by surgical repositioning

Fig. 7. Orthodontic decompensation before maxillary advancement. (A, B) Facial photos after completion of the first orthodon-

tic treatment, which was directed at modifying tooth position to fit the skeletal relationship. (C, D) Facial photos after maxillary

advancement. (E–G) A second orthodontic treatment was initiated (at a time matching A and B) to retract the maxillary ante-

rior teeth into extraction spaces and the result after maxillary advancement. (H ) The dental occlusion before cosmetic bonding.

(I ) Lateral radiograph matching (E). (J ) Lateral radiograph matching (F). (K) Superposition of tracings of (I ) and (J ) showing

amount of advancement.


Fig. 7 (continued).


replacement of teeth. Fig. 8 shows how a posterior

maxillary osteotomy was used to advance the lesser

segment in a patient with a unilateral cleft lip and

palate. Such movements also may be accomplished

using osteodistraction techniques [51,52].

Maxillary distraction is particularly valuable in

patients with clefts in whom palatal scarring may

limit the amount of advancement possible at the time

of the osteotomy [53–55]. Figs. 9, 10 show two

patients who underwent maxillary distraction. The

first patient (see Fig. 9) was in the stage of early

mixed dentition and marked advancement was ob-

tained. Just as in frontofacial advancement for patients

with craniofacial synostosis, however, the maxilla is

unlikely to grow normally after repositioning and ad-

ditional interventions are likely to solve the aesthetic

Fig. 7 (continued).

Fig. 8. Surgical advancement of the lesser segment was p

fistula. (A, B) The initial malocclusion. (C, D) The expansio

(G, H) Postoperative views.


and occlusal issues that will recur with future growth.

Fig. 10 shows an example of maxillary distraction in a

mature person. There is marked facial improvement,

but some dental compensation resulted from using the

maxillary teeth as anchors for the device and from

using class III elastics to finalize the occlusal relation-

ships. One solution to avoid the dental side effects

may be to use implants for anchorage in distraction

patients as has been done for protraction facemask

therapy [40].

erforme

n applia

Stability is an issue following both standard

orthognathic procedures and distraction osteogenesis.

After Le Fort I osteotomies in patients with unilateral

and bilateral cleft lip and palate, a relapse of approxi-

mately 9% horizontally and 17% vertically was noted

in both groups [56]. It has been suggested that wear-

ing a facemask postoperatively will enhance stability

and provide an alternative to class III orthodontic

elastics [57]. The resolution of third molar problems

also should be accomplished before the end of the

retention period.

Monitoring growth and development

Orthodontists monitor growth and development of

the face, dental arches, and teeth by comparing the

individual patient’s condition to normal standards and

expected patterns for comparable patients as reported

in the literature. A general theme throughout the lit-

erature on patients who have treated clefts [58–66] is

that it is difficult to make clear distinctions between

outcomes of specific procedures because individual

variability is high and experimental groups usually

are small. Two persistent questions therefore have not

been answered adequately: timing of surgical inter-

ventions and predicting growth. Cases can be found

to demonstrate advantages of early or late treatment,

but generalizable conclusions based on analysis of

sufficient data from scientifically selected treatment

groups are sparse. Clinicians want to be able to pre-

dict the outcome for treatment planning and for other

concerns [67–70], such as linking the initial arch-

form or early occlusal relationships with later severity

of malocclusion, being able to tell prospective parents

d to close the edentulous space and eliminate the oronasal

nce. (E, F) Views before surgical movement of the segment.

Fig. 8 (continued).


if they have increased chances for cleft offspring

because of their own distinctive craniofacial mor-

phology, and determining ultimate costs of treatment

in financial terms.

Tooth anomalies present in cleft lip/palate in-

volve all phases of tooth development and result in

abnormalities in number, shape, size, color, timing

of development, and position [71–78] (Fig. 11). Teeth

may be missing because of natural exfoliation, agene-

sis, or iatrogenic reasons. Some patterns of agene-

sis have been linked to mutations in PAX 9 and

MSX1 homeodomains.

The literature’s reported rates of missing teeth in

patients with clefts may include some iatrogenic

losses, such as those maxillary anterior teeth or their

anlagen removed during early surgical procedures. In

addition, specific teeth are absent on the non-cleft

side at rates greater than occur in normal individuals,

which is of great interest in terms of etiology. Solis

et al [72] found that teeth adjacent to clefts had de-

layed maturation relative to their antimeres in the

same mouth and as compared with control values;

this information is important when determining the

optimal time for secondary bone grafts by ratings of

Fig. 9. Maxillary distraction in a patient with a cleft in the early mixed dentition stage. (A, B) Pretreatment. (C, D) After

advancement of the maxilla. (E, F) Pre- and postadvancement views of the dental occlusion. (G) Superposition of pre- and post-

treatment cephalometric tracings. (H, I) Fabrication of the attachment apparatus from an orthodontic headgear frame and

orthodontic bands.


Fig. 9 (continued).


Fig. 10. Maxillary distraction in a mature patient with a cleft. (A–D) Pre- and post-treatment facial photos. (E–G) Initial, during

distraction, and post-treatment cephalometric radiographs. (H, I) Pre- and postdistraction dental occlusion.


Fig. 10 (continued).


Fig. 11. (A–C) Tooth anomalies present in individuals with clefts may involve number, shape, size, color, timing of devel-

opment, or position.


root development. Characteristic malocclusions ac-

company each type of repaired cleft and these vary

from malocclusions occurring in comparable untreat-

ed individuals who have clefts.

Summary

Orthodontic strategies continue to evolve as new

methods and treatment concepts more directly ad-

dress the specific problems of patients who have

clefts. By continual review of treatment outcomes

and comparing outcomes with patients’ problem lists

and treatment objectives, clinicians will identify areas

of treatment needing improvement and formulate

hypotheses for future research.

Acknowledgments

The author thanks Adriana Da Silveira, Budi

Kusnoto, Keum-Ryung Kim, Leslie Heffez, Mimis

Cohen, John P. Kelly, and John B. Mulliken for their

participation in the treatments shown in this article.

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Orthodontic treatment for patients with clefts