This document summarizes guidelines for the management of cleft lip and palate, including neonatal care and feeding, naso-alveolar molding techniques, and primary repair of unilateral cleft lip. It discusses the challenges of feeding in cleft lip and palate patients, guidelines to address these challenges, and the use of various feeding appliances. It also provides details on Grayson's technique for naso-alveolar molding to reduce the cleft deformity, including the objectives, procedure, and potential complications. Finally, it covers considerations and techniques for primary repair of unilateral cleft lip, including the goals and timing of repair.

1. Dr. Vijai S
Reader
Dept of Pedodontics
Malabar dental college
1
Management of cleft lip and palate

2. Genetic
counseling

3. Neonatal Care and Feeding Guidelines
3
 It is important to address parental anxiety and
trauma
 Early contact and counseling
 Explanation of normal and altered anatomy and
physiology can guide toward successful feeding.
 The normal process of feeding involves sucking
and swallowing.
 In patients with cleft lip with alveolus, it is not a
problem and can be achieved with slight
adjustments such as placing a finger over the
cleft. This creates negative pressure inside the
oral cavity and results in effective swallowing.

4. 4
 In cleft palate patients this pressure cannot be
built up as air is drawn out through the defect to
the nose.
 A variety of nipples and feeding devices are
available which include; Lambs nipple, enlarged
cross cut nipple, Mead Johnson Cleft palate
nursing bottle.
Guidelines during feeding:
 The infant is positioned at 45-60 degrees angle to
decrease nasal regurgitation.
 The nipple is directed to the intact part of the
palate.
 The child is burped frequently because of
excessive air swallow.

5. 5
 Adjust the flow of milk to the ability of the child to
swallow.
 Observe the child for choking, cyanosis and
abdominal distension.
 Use feeding appliances if required.
Feeding appliances:
 These should be considered if other methods are
not successful in the first two weeks.
 They seal the oro-nasal fistula and enable the
child to suck by negative intra-oral pressure.

6. 6
 Procedure:
 Alginate impression: the tray should extend from
maxillary frenum at the cleft lip site, posteriorly past
the end of the alveolar ridges into the palate, and
laterally to include the lateral mucobuccal fold.
 In bilateral cleft applainces the finish line is not placed
in the anterior area. The bilateral segments are
supported uniformly from the lateral position which
allows premaxilla to drift posteriorly under lip
pressure.
 The cleft area and superior aspect of nasal passage
should be waxed out during fabrication of the plate.
 A small hole should be placed anteriorly in the plate to
tie a dental floss to the appliance.

7. 7

8. Maxillary Orthopedics /
Naso-alveolar molding.
8
 Cleft lip and palate can present with considerable
variation in severity and form.
 Generally, the wider more extensive clefts are
associated with more significant nasolabial
deformity.
 These clefts, deficient in hard and soft tissue
elements, present a significant surgical challenge
to achieve a functional and cosmetic outcome.
 From a surgical viewpoint, chances of achieving a
finer surgical scar, good nasal tip projection and
more symmetrical ,well defined nasolabial
complex would be better if the infant presents
with a minor cleft deformity.

9. 9
 A fine scar forms when a surgical incision heals under
less tension.
 Thus, the principal objective of presurgical
nasoalveolar molding (NAM) is to reduce the severity
of the initial cleft deformity.
 This enables the surgeon and the patient to enjoy the
benefits associated with the repair of a cleft deformity
which is of minimal severity.
 Neonatal maxillary orthopedics is usually initiated
during the first or second week following birth, in
absence of other medical complications, and may be
carried out by the orthodontist, the pedodontist, or the
prosthodontist.
 However, there is still a lack of agreement on early
management due to the lack of controlled studies that
show better outcome with maxillary orthopedics.

10. 10
Historical perspective:
 Numerous techniques have been documented
over the centuries to improve the position of cleft
alveolar segments.
 In 1686, Hoffman described the use of a head
cap with arms extended to the face to retract the
premaxilla and narrow the cleft.
 The modern concept of an intra-oral device to
reposition the cleft alveolar segments was
introduced by McNeil (Univ. of Glasgow) in 1950.
Through a series of acrylic plates, the segments
were actively molded into the desired position

11. 11
 In 1969, Rosenstein introduced the concept of
passive control of cleft segments. Through the
use of a passive appliance, the continuous force
of the repaired lip could be used over time to
attain a more normal arch contour, with the cleft
segments coming together to form a butt joint.
 In 1975, Georgiade and Latham introduced a pin-
retained appliance to simultaneously retract the
maxilla and expand the posterior segments over
a period of days.

12. 12
 During the 1980s, original research for molding
cartilage was performed by Matsuo. He
recognized that the cartilage in the newborn is
soft and lacks elasticity. This was attributed to
high level of estrogen at the time of birth, which in
turn led to increased hyaluronic acid levels
 Hyaluronic acid inhibits the linking of the cartilage
intercellular matrix, and may be necessary to
relax ligaments, cartilage and connective tissue
enabling the fetus to pass through the birth canal.

13. 13
 The level of estrogen begins to decline
immediately after birth.
 Matsuo used a stent in the form of silicone tubes
to shape the nostrils.
 Grayson (1993) adapted the nasal stent to extend
from the anterior flange of an intra-oral molding
plate.
 Advantages of this method are: Skillful application
of force for nasal molding, and no need for intact
nasal floor.

14. 14
 The popularity of maxillary orthopedics was well
accepted in the 1960’s and 1970’s, to eliminate
the need for subsequent orthodontic treatment.
 Later reports suggested that although the initial
results of lip repair were easier to attain with
cosmetic improvement, there was no long term
benefit on the growth of the midface and dento-
alveolus.

15. 15
 Additionally, early or primary bone grafting
associated with maxillary orthopedics at time of
primary lip repair may have compromised the
long-term follow up of treated patients.
 Thus, the use of neonatal orthopedics before
primary surgical lip repair became a matter of
controversy between clinicians.
 The current perspective is that neonatal maxillary
orthopedics, when provided as an adjunctive
procedure to primary definitive lip repair, does
have presurgical benefits.

16. 16
 In general, appliances for use in cleft care can be
classified as follows:
 Active and passive.
 Extra-oral and intra-oral.
 Huebner and Liu( Clinics in Plastic Surgery 1993)
advocated the use of passive acrylic appliances
to mold the alveoli under pressure from the
repaired lip.

17. 17

18. Grayson’s Technique for Naso-alveolar
molding (Clin Plastic Surg 2004)
18
Objectives:
 Reduce the severity of initial cleft deformity.
 Lip segments almost in contact at rest.
 Symmetrical lower lateral alar cartilages.
 Adequate nasal mucosal lining.
 Uprighting of inclined columella.

19. 19
AIMS
 non-surgical elongation of the columella,
 centering of premaxilla
 slow gentle retraction of the premaxilla
 reduction in width of nasal tip, alar base.

20. 20
Procedure:
 Heavy bodied silicone impession material is used
to take initial impression soon after the birth,
when cartilage is plastic and moldable.
 Infant is held upside down by surgeon and the
impression tray inserted into the oral cavity,
seated till impression material just starts to
extrude past posterior border.
 A stone model is poured, and a molding plate
fabricated on it with clear hard acrylic lined with a
thin layer of soft denture material.

21. 21
 Care should be taken to relieve the plate in area
of labial frenum and other areas likely to ulcerate.
 Parents are instructed to keep the plate in full
time and take it out for cleaning once a day.
 The appliance is secured extra-orally to the
cheeks and bilaterally by surgical tapes, with an
orthodontic elastic band at one end.

22. 22
 The elastics loop over a retention arm extending
from the anterior flange of the plate at 45º to the
horizontal.
 This prevents unseating of the appliance; tapes
are changed once a day.
 The retention arm is positioned at a point on the
labial border of the plate corresponding to the
junction of the cleft lip segments, when pulled
together. Vertically it should be at junction of
upper and lower lips at rest.

23. 23
 Weekly visits are required to modify the molding
plate.
 Closure of the alveolar gap brings the lip
segments together, reduces the nasal base width,
and introduces laxity of the alar rim.
 Care should be taken not to add the nasal stent
before achieving laxity of the alar rim, else
increase in nostril circumference may result.
 Elastics attached to the retention arm should
exert a force of approximately 2 oz.
 Retraction of premaxilla as in bilateral clefts
requires higher force levels.

24. 24
 Lip taping: At the 3rd visit, the parents are
instructed to place tapes to approximate the cleft
lip segments. Tape should be applied at the base
of the nose, on the non-cleft side first, then
pulled over and adhered to the cleft side.
 Philtrum and columella should be brought to the
midline.
 Note: Taping too low can cause undesirable
horizontal lengthening of the lip over time.
 Advantage: Lip taping provides some of the
benefits of a surgical lip adhesion without the
associated surgical morbidity, cost, and scarring.

25. 25
 The Nasal Stent: When the cleft alveolus is
reduced to 5 mm or less, the nasal stent is
added.
 The stent is made of 0.036 gauge round stainless
steel wire and takes the shape of a swan neck.
 It is attached to the base of the retention arm,
extends forward and then curves backward
entering 3-4 mm past the nasal aperture.

26. 26
 As the wire extends into the nostril, it is curved
back on itself to create a small loop for retention
of the intranasal portion of the nasal stent.
 This is a hard acrylic kidney shaped component,
with an added layer of soft liner

27. 27
 The upper lobe enters the nose and gently lifts
the dome till moderate tissue blanching is seen.
 The lower lobe lifts the nostril apex and defines
the top of the columella.
 A vertical tape from the prolabial band extends
downward to engage the retention arms with
elastics. This helps to lengthen the columella
nonsurgically.

28. 28
 In the patient with bilateral clefts, there is a need
for two retention arms and two nasal
splints.Fabrication steps are same as described
for a unilateral cleft.
 In addition, a horizontal “prolabial band” of soft
denture material is added to join the lower lobes
of the two stents, spanning the base of the
columella.

29. 29

30. 30
Complications associated with Naso-alveolar molding:
 Irritation of oral mucosal or gingival tissue.
 Heavy application of force by upper lobe of nasal
stent, resulting in inflammation of nasal mucosal
lining.
 Notching of alar rim due to incorrect position or
shape of lower lobe of nasal stent.
 Irritation of cheeks due to adhesive tape. The tape
should be removed slowly or gently, or warm water
may be used. Else, a skin barrier can be used as a
base for the elastic attachment.
 Taping the arms too horizontally or with inadequate
activation may lead to posterior dislodgement of the
plate.
 A 5 mm hole can be placed in the palatal portion of
the plate to maintain airflow.

31. Primary repair of unilateral cleft lip:
31
Anatomic Considerations:
 The superficial muscles of the face are arranged
schematically in 3 interdependent rings.
 These muscles include the transverse nasal
muscle, levator labii superioris alaeque nasi,
levator labii superioris, depressor septi,
orbicularis oris.
 In patients with clefts, these muscles do not insert
on their corresponding elements on the medial
side of the cleft.
 As a result they are prolapsed laterally, and
cannot solicit stimulation and normal growth.

32. 32
 The nasal septum is pulled by muscles on the
non cleft side, displacing it with the anterior nasal
spine in that direction.
 On the cleft side the labial commisure is deviated
latero-inferiorly, which in turn favors lateral
deviation of the chin to the cleft side.
 This accentuates the nasal asymmetry and the
entire anterior part of the face is distorted and
malformed.

33. 33
The goal of primary closure is not only to
re-establish normal insertions of all the
naso-labial muscles but also to restore the
normal position of all the other soft tissues,
including the muco-cutaneous elements.

34. 34
Timing of repair
 There is still some controversy about ideal time for
cleft lip repair.
 Most surgeons abide by the rule of 10s.
 General anesthesia is usually necessary for surgery
and is safe when the infant is 10 weeks of age, 10
lbs in weight and has a Hb level of 10g.
 Recently there has been discussion of early repair in
the first 1-2 weeks of life: not common yet.

35. 35
Lip Adhesion:
 Some surgeons prefer to perform a preliminary lip
adhesion before definitive lip repair.
 Particularly done in extremely wide complete
clefts with marked maxillary and nasal distortion.
 Reduces the actual deformity by helping to mold
the maxillary segments closer together
 May make formal lip repair less difficult.

36. 36
 Technique involves paring of cleft margins and a
3 layer repair including mucosa, muscle and skin.
 This converts the complete cleft into an
incomplete one.
 Non-surgical lip adhesion with tape has also been
reported to be of benefit.
 However, current opinion among some authors is
that lip adhesion is an unnecesary procedure.

37. 37
 According to Salyer et al (Clinics in Plastic Surgery,
April 2004):
 Lip adhesion may contribute to additional scarring or
abnormal tethering of the lip or nasal elements.
 Using a lip adhesion treats the abnormal skeletal
base, making it easier for the surgeon to close the lip
at the expense of overall esthetics of nose and lip.
 May cause fixation or scarring of the alar base or
associated adjacent structures in an abnormal
position, making definitive normal contour of nose
more difficult.
 The utility of naso-alveolar molding in early treatment
of unilateral cleft lip and palate has also been
challenged recently.

38. Techniques of lip repair
38
 Early lip repairs involved paring the lip margins
and repair of skin and mucosa without muscle
realignment.
 The orbicularis oris muscle therefore maintained
its abnormal attachments resulting in an
orbicularis bulge in the lateral lip segment.
 Nowadays it is standard practice to detach the
muscle from its abnormal skin and mucosal
attachments and reorient it in a proper fashion.

39. 39
1. Straight line technique (Rose-Thompson)
 Used in case of an incomplete cleft lip that
requires minimal lengthening.
 Slightly curved or angled incisions of equal
length are made on either side of the cleft ,
which, after suturing, create a philtral scar line
symmetric with normal philtral column.
 Formal muscle repair is also done.

40. 40
2. Triangular Flap technique (Tennison-Randall)
 Used in situations where maximal lengthening of
the lip is required.
 Precise reproducible mathematical markings as
described by Randall are used, allowing excellent
results even by relatively inexperienced
surgeons.
 Scar line crosses the philtrum in lower portion of
lip, which may be unesthetic.

41. 41
3. Millard’s Rotation Advancement Technique:
 One of the most popular cleft lip repair techniques
in the USA.
 Described by Millard as a cut as you go technique
and is not easy to master.
 Rotation and advancement flaps are marked and
adjusted during the procedure to provide
adequate lip length.
 Scar line crosses upper philtrum column.

42. 42
4. Modified Rotation Advancement Flap (Mohler,
1986):
 Produces a scar line that more closely mimics the
normal philtral column, than original Millards
technique.
 Achieved by extending the rotation incision into the
columella and making a back-cut.
 Muscle repair is also performed.
 Lengthening of columella occurs.
 Scar line is more vertical and lateral in the upper
lip, which appears more natural.

43. Primary Repair of Cleft Palate:
43
 Primary cleft palate repair is indicated in nearly all
affected children to facilitate speech and
swallowing.
 Earlier, primary repair was performed at 18-24
months of age, but recent advances in anesthesia
and surgery allow early cleft palate repair at 9-12
months of age.
 An infant is generally ready for repair when able
to drink from a capped cup without a nipple.

44. 44
Advantages of early repair of cleft palate:
1. Encourages normal speech patterns.
2. Permit normal swallowing patterns.
3. Allow eustachian tube to function against a
repaired palate.
4. Help parents lead the child through tasks of
development with less difficulty.

45. Contra-indications to early repair:
45
1. Children with upper airway obstruction
2. Severe retrognathia
3. Persistent glossoptosis as occurs in Robin
sequence.
4. Children at risk of excessive blood loss,
delayed wound healing
5. Increased anesthetic risk.

46. Goal of cleft palate repair:
46
To create normal function in the hard palate and
soft palate.
Simple obturation of the cleft never permits
normal function.
It requires realignment of all the associated
tissues (mucosa, submucosa, muscle, nerve,
vessel, and bone) to create a functional structural
unit.

47. Pathologic anatomy of the cleft
palate:
47
 Four muscles with various degrees of fusion
compose the soft palate and produce its primary
functions of elevation, obturation of the nasal
pharyngeal opening, and traction on the
eustachian tube during swallowing.
 4 muscles are
 tensor veli palatini,
 levator veli palatini,
 uvulus,
 palatopharyngeus.

48. 48
 The muscles that normally join at the midline of the
soft palate, course anteriorly and insert on or near
the posterior edge of the hard palate.
 In cleft palate patients, the attachments of these
muscles in the soft palate are defective
 Result in defective function of the soft palate lead to
1. compromised sphincter function,
2. velopharyngeal insufficiency,
3. problems in speech,
4. chronic otitis media,
5. risk of permanent hearing loss.

49. Surgical repair of cleft palate
49
 The French dentist LeMonnier performed the first
surgical repair of a congenital cleft palate in the
1760’s.
 The 3 stage operation consisted of passing
sutures through the cleft borders, cauterizing the
cleft edges, and realigning the fresh edges.
 By the early 20th century, goals included
lengthening of the palate to improve speech in
the cleft patient.
 In the past few decades, attention has shifted to
achieving optimal speech development and
avoiding abnormal growth after repair.

50. Techniques of surgical repair:
50
Incomplete clefts of soft palate:
1. Side-to side veloplasty:
Veau, in the early 20th century repaired clefts of
soft palate by bringing together the cleft
edges,without suturing together the muscle
bundles.

51. 51
2. Kriens Intravelar Veloplasty:
 Proposed by Kriens in 1969
 Restores the levator sling and the palatal
musculature at the midline where they normally
meet.
 Accomplished by dissecting anteriorly
malpositioned bundles from posterior edge of hard
palate and repositioning them in the midline.
 The effectiveness of Krien’s technique over
conventional veloplasty has not yet been
demonstrated in randomized, prospective,
controlled studies.

52. 52
3. Furlow double opposing Z-plasty
 Has become the veloplasty of choice for many
surgeons, over the past decade.
 Uses two reversed Z plasties based upon the
cleft midline, both of which draw in soft palate
tissue from the sides to close the cleft defect and
restore the musculature to its anatomic position.

53. 53
Incomplete clefts of hard and soft palate
1. Von Langenbeck’s technique (1859)
 This technique depends on paring the edges of
the cleft and separating the oral and nasal
mucosa.
 Releasing incisions are made, hard palate is
elevated bilaterally to allow mucosal closure.
 The nasal mucosa and oral mucosa are sutured
side to side to form a 2 layered closure.
 Generally used for cases of incomplete clefts of
hard and soft palate.

54. 54
2. Veau-Wardill-Kilner (VWK) palatoplasty
 Modification of von Langenbeck technique
 Involves medial and posterior movement of left
and right palate.
 Purpose is to increase palatal length to improve
velopharyngeal function.
 Accomplished via a V-Y lengthening done at the
anterior hard palate.

55. 55
Concerns with the VWK palatoplasty:
Denudation of palatal bone anteriorly, which may
adversely affect midfacial growth in cleft palate
patients. (La Rossa D. Cleft Palate Craniofac J
2000)
A recent retrospective study (Pigott et al. Cleft Pal
Craniofac J 2002) comparing the von Langenbeck
and VWK techniques, found that over a 5 year
period, maxillary growth was less affected with the
von Langenbeck Technique with releasing incisions.

56. 56
Complete bilateral cleft palate:
 Presents a unique challenge because of cleft width
and continuity of the palatal cleft with clefts of the lip
and alveolus.
 Technique for repair: two flap palatoplasty,which is
similar to the VWK repair but involves more
extensive dissection anteriorly to encompass the
cleft edges at the alveolus.
 May be combined with a vomer flap, for closure of
nasal mucosa and buccal flaps,to cover denuded
areas of the palate :four flap palatoplasty.
 Mann and Fisher (Plast Reconstr Surg 1997) have
documented the use of bilateral buccal flaps in
conjunction with a modified Furlow repair to cover
denuded areas on the posterior hard palate.

57. Post-operative care:
57
 Average blood loss for the procedure is 50-60 ml
and the length of procedure is 12 hours.
 Post-op. monitoring with pulse oximetry;
observation for hemostasis and respiratory
distress.
 Adhesive arm restraints for 10 days to prevent
patient from placing objects in the mouth.
 Diet of clear fluids initiated on 1st post-operative
morning.
 A patient who has adequate oral intake, is in no
distress and meets usual discharge criteria may
be sent home on the 1st post-operative afternoon.

58. Comprehensive orthodontic
treatment:
58
Aims :
1. To prevent gross deformity of dental arches.
2. Restore normal overall contour of upper arch
3. Relate the upper and lower dental arches, by
expanding the upper arch as required, and
extracting in the lower arch if necessary.
4. To encourage proper functional exchange
between the arches.

59. 59
6. To create more room for tongue, facilitating
articulation.
7. Prepare the dentition for secondary bone
grafting, prosthetic rehabilitation, orthognathic
surgery.
8. To improve the appearance of the profile and
facial contours.

60. Timing and sequence of treatment
(4 periods)
60
I. Neonate and infant (Birth to Two Years)
Presurgical orthodontics, maxillary orthopedics.
Feeding plates, Passive molding plates, Elastic
straps.
Nasal Stents.

61. 61
II. Primary Dentition (2-6 years of age)
 Establishment of primary dentition permits
classification of the type of developing
malocclusion, which is an important part of
diagnostic regimen.
 Anterior crossbite may be seen unilateral/
bilateral, with or without mandibular shift.
 Orthodontic treatment may be required to remove
interfering contacts in order to eliminate
mandibular shift.
 If the dental crossbite relationship is a continuing
problem, it may reflect an underlying skeletal
discrepancy. This may require growth
modification with face mask.

62. 62
 According to Vig and Mercado, contemporary
opinion recognizes a need for orthodontic
treatment in the early mixed and permanent
dentitions.
 No strong evidence supports a benefit from
routinely treating dental malocclusions in the
primary dentition.
 Treatment may be deferred till it can be combined
with other treatment goals.

63. 63
III. Mixed dentition Stage (7-12 years of age)
Goals of treatment at this stage include:
1. Lateral expansion of the posterior segments if
required, using palatal expanders incorporating
screw, or quad helix.
Puneet Batra, Ritu Duggal and Hari Parkash
(JIOS 2003) reported on the use of a Nickel
Titanium Palatal Expander which is temperature
activated and produces light continuous pressure
(230-300 gms) on the mid palatal suture. They
documented three cases of CL/P which were
treated with this modality to correct crossbite and
molar relation.

64. 64
 The maxillary arch should not be over-expanded ,
or else the alveolar defect would be widened. It
should be sufficient to improve arch form and
correlate it with lower arch.
(Note: If grafting is done prior to expansion of the
maxilla, a 3 month period must elapse before
attempting expansion.)
2. Correction of incisor malalignment and displaced
teeth.
3. Resolution of anterior crossbite.

65. 65
4. Growth modification:
Children treated for cleft lip and palate often
develop midfacial retrusion.
In order to avoid the need for later surgery,
growth modification by protraction of the maxilla
and restraint of mandibular growth may be
attempted.
Facemask and reverse headgear have been
used to achieve correction of skeletal
discreopancy.
Buschang et al (Angle 1994) evaluated 20
children with UCLP, treated at 7.3 years of age,
with a combination of maxillary expansion and
facemask therapy. Their results showed that
although skeletal changes are limited, they do
produce marked improvements in the soft tissue

66. Skeletal and dental effects of reverse
headgear
66

67. Use of implants for maxillary protraction
67
 Use of conventional face mask therapy using the
maxillary dentition as anchorage may be
associated with anchorage loss in the form of
maxillary dental protrusion.
 Osseointegrated implants can be used to provide
unlimited anchorage for protraction.
 Singer et al (Angle Orthod 2000) reported a case
in which Branemark Implants were placed in the
zygomatic buttresses of the maxilla in a 12-year
old female patient with a Class III malocclusion
associated with unilateral cleft lip and palate
defect.

68. 68
 The implants were left to integrate for 6 months
followed by placement of customized abutments
that projected into the buccal sulcus
 Elastic traction (400 g per side) was applied from
a facemask to the implants at 30 degrees to the
occlusal plane for 14 hours / day for 8 months.
The maxilla moved downward and forward 4 mm
rotating anteriorly as it was displaced.
 Clinically, this resulted in an increase in fullness
of the infraorbital region and correction of the
pretreatment mandibular prognathism.
 There was an increase in nasal prominence as
the maxilla advanced. This contributed to the
increase in facial convexity.

69. 69
The secondary dental change frequently seen in
standard facemask therapy was avoided.

70. 70
 In the future, new protraction devices may use
short-duration dynamic forces rather than
continuous forces as currently delivered.
 Current research on the mechanobiology of the
sutures is exploring the response of cells to
oscillating mechanical signals. ( Mao, J Dent Res
2002)

71. Alveolar bone grafting
71
Purpose: Not simply to close a hole in the
alveolus but also to accomplish certain esthetic
and functional goals.
These goals are:
 Closure of oronasal fistula
 Stabilization of the lesser segment
 Adequate bone support for teeth adjacent to the
cleft.
 Allow for eruption of teeth in the cleft area (lateral
incisor or canine) with good bony support.

72. 72
 Augmentation of piriform region.
 Establish good soft tissue contours with adequate
keratinized gingiva for periodontal health.
 Minimize growth disturbances

73. Historical aspects:
73
 The first reports of maxillary alveolar bone
grafting appeared in the German literature in the
early 20th century with reports by Lexer and
Drachter.
 Boyne and Sands in 1972, desribed a successful
protocol for secondary alveolar bone grafting,
using the ilium as the donor site, which has
become the standard technique, the world over.

74. 74
Timing of repair:
 Timing of repair has been controversial.
 From a chronologic viewpoint it may be primary or
secondary.
 Primary repair occurs between birth and the age
of 2 years, and is typically performed at the same
time as lip repair, or later but before palate repair.
 Long term studies in the 1970s and 1980s
showed primary repair is associated with higher
incidence of detrimental growth effects such as
midface retrusion and anterior crossbite.

75. 75
Early secondary repair is done if the patient
appears to have a functional lateral incisor that
can erupt into the grafted cleft site.
 This is performed when the lateral incisor root is
2/3rds – 3/4th formed.
 Morphology of the lateral incisor is an important
consideration.
Conventional secondary repair as described by
Boyne and Sands is performed generally at the
age of 9-11 years just before the eruption of the
canine tooth.
 Done in cases where early repair is not
warranted.
 Vast majority of patients fall into this category.

76. 76
 This age is believed to be appropriate because
sagittal and transverse growth of the maxilla is
essentially complete by the age of 8 years, and
remaining vertical growth is from eruption of
permanent teeth.
Tertiary repair: Done after the eruption of the
permanent dentition (usually the 2nd permanent
molars)
 Shown to have a lower success rate compared to
conventional secondary grafting.
 Gradual loss of bone along the distal surface of
central incisor root and mesial surface of canine
root limits the bone graft “take”.

77. Role of the orthodontist in alveolar cleft
grafting:
77
 Orthodontist plays an essential role.
 In infancy, maxillary orthopedics is carried out to
expand the collapsed lesser segment, mold the
anterior maxillary arch and reduce the alveolar
gap.
 Prior to secondary bone grafting, further
orthodontic treatment is required.

78. 78
This includes:
 Placement of fixed appliance on the maxillary
arch.
 Expansion of the anterior and posterior maxilla to
develop favorable arch form, partially or
completely eliminate crossbites.
 Alignment or derotation of malpositioned incisors.
 Improvement of dental function and esthetics.
Approximately 4-6 months of orthodontic
treatment should be anticipated in preparation for
alveolar bone grafting.

79. 79
 Bone grafting of the alveolar cleft without proper
orthodontic preparation will lead to poor results
with malposition of the lesser segment, a
stabilized maxillary arch constriction, and
posterior crossbite.
 Correction of these will necessitate additional
surgical procedures.

80. Bone graft donor sites:
80
 The gold standard site in alveolar cleft repair is he
iliac crest, typically harvested as a a particulate
cancellous bone and marrow (PCBM) graft.
 Provides the greatest volume of cancellous bone
available among commonly used sites.
 Success rates using cancellous iliac bone have
been reported to be usually greater than 80%.
 Limited dissection of muscle and periosteum,
along with use of percutaneous trephine method
have reduced postoperative pain substantially.

81. 81
 Bergland et al of the Oslo study group reported
high rates (85%) of spontaneous eruption of the
canine following bone grafting. Another 15%
required forced eruption.
 Da Silva Finho et al (Angle Orthod 2000)
reviewed the literature pertaining to successful
eruption of permanent canine following secondary
alveolar bone grafting and found it to vary from
27% to 95%.
 In their own sample of 50 patients treated with
secondary alveolar bone grafting, the authors
reported spontaneous eruption of the canine
through the graft in 72% of cases, while in
another 6%, orthodontic traction succeeeded in

82. 82
 Other sites which have been investigated are the
tibia, the calvarial bone and mandibular
symphysis.
 Tibial bone provides sufficient cancellous bone,
but disadvantages are a visible scar and
possibility of damage to epiphyseal growth plate.
 Calvarial bone and mandibular symphysis bone
have the advantage of being located in the facial
skeleton and arise from membranous bone. This
gives the theoretical advantage of less overall
resorption.
 Disadvantage: Provide much smaller quantity of
cancellous bone, making them inappropriate for
larger clefts.

83. Procedures involved in alveolar bone
grafting:
83
 Layered closure of the oro-nasal fistula is
achieved.
 The oro-nasal fistula is incised and two sets of
flaps are created: nasal and oral mucosal layer.
 Nasal closure is performed before placing the
bone graft and the oral closure.
 Buccal and palatal flaps need to be raised for
proper closure of the alveolar cleft.
 After closure of the nasal and palatal flaps, the
bone graft is placed over the inferolateral pyriform
rim, to augment the alar base.
 Following this, the buccal flaps are closed.

84. Innovations in repair of cleft sites:
84
 Platelet rich plasma is an autologous source of
growth factors that has been shown to accelerate
the rate and degree of bone formation in a bone
graft.
 Obtained by centrifuging autologous blood into its
basic components.
 Rich source of growth factors such as PDGF,
TGF, which have been shown to play important
roles in bone regeneration and repair.
 Approximately 60-100 cc of whole blood is
recommended to provide an adequate amount of
PRP.

85. 85
Composite intramenbranous bone grafts:
 In an effort to augment the healing of autogenous
EC bone, Rabie and Lie (Int J Oral and Maxillofac
Surg 1996) mixed the autogenous EC bone with
demineralized endochondral bone matrix
(DBMEC). This composite endochondral bone
graft (EC-DBMEC) produced 47% more bone
than autogenous EC bone alone.
 Similar results were obtained when autogenous
IM bone mixed with DBM, prepared from IM bone
in origin, produced 204% more bone than the IM
bone alone.

86. 86
 Rabie and Chay (AJODO 2000) reported a case
of cleft lip and palate with a large alveolar defect
in which bone harvested from the chin mixed with
DBM was used successfully.

87. 87
 Distraction osteogenesis has also been used by
Liu et al (Plastic Reconstr Surg 2000) to close
large alveolar clefts that would otherwise have
been difficult to close using conventional
methods.
 Yen et al (JOMS 2001) have also reported the
use of a modified distraction device for closure of
cleft spaces.

88. 3. Permanent dentition stage treatment
88
 The permanent dentition is associated with the
adolescent growth spurt and onset of puberty,
during which time the skeletal discrepancy
becomes more accentuated and occlusal
relationships deteriorate.
 Sagittal maxillary deficiency coupled with vertical
maxillary deficiency may result in overclosure of
mandible accentuating the Class III tendency.
 Transverse discrepancies may be accentuated by
the Class III sagittal relation and lead to posterior
crossbites.
 As the patient matures, a decision has to be
made whether the patient can be treated by
orthodontics alone or in combination with
orthonathic surgery.

89. 89
This requires full face and profile assessment as well
as cephalometric analysis and prediction tracings.
If the skeletal discrepancy is mild and esthetic
concerns are minimal, dental compensation by
orthodontic treatment alone may be recommended.
This would involve full banded/ bonded appliances
with use facemask therapy upto the beginning of
adolescent growth spurt.
Extractions may be required for corection of crowding.
Use of Class III elastics in patients with vertical and
sagittal discrepancies.
 Caution must be exercised, as the patient may
outgrow the dental correction, ultimately requiring
surgery.

90. 90
 In case orthognathic surgery is required, the
orthodontist must perform necessary presurgical
orthodontics to decompensate the dentition, for
maximal skeletal correction.
 12-18 months of pre-surgical orthodontics are
usually necessary to align the teeth, correct axial
inclinations, dental midline discrepancy, co-
ordinate arches and localize space for prosthetic
replacement of teeth.
 Placement of full-size archwires with lugs
provides a means for rigid intermaxillary fixation
at time of surgery.
 After surgery, post-surgical orthodontic detailing
of occlusion is achieved in 4-6 months.

91. Orthognathic surgery for the cleft patient
91
Timing of orthognathic surgery
 Orthognathic surgery should be delayed till
skeletal maturity has been achieved as
documented by hand wrist radiographs or
sequential cephalometric radiographs taken at 6
month intervals.
 Usually at 17 years for girls and 18-20 years for
boys.
 Velopharyngeal function must be evaluated prior
to surgery as it may be disturbed by Le Fort I
advancement of maxilla leading to
velopharyngeal incompetence.
 The LeFort I osteotomy is the most favored
technique by authors for correction of sagittal

92. 92
 Two jaw surgery i.e combination of maxillary
advancement and mandibular setback is
indicated when there is a true mandibular
prognathism, or if there is maxillary retrognathia
of more than 10-12 mm.
 Segmental osteotomy: Is done if the greater
maxillary segment is in a good position, but the
lesser segment is medially and posteriorly
displaced.
 LeFort II osteotomy: Indicated in patients with
severe paranasal hypoplasia extending to the
infra-orbital rims.
 Premaxillary osteotomy: Done in patients with
repaired BCLP who have protruded and rotated
premaxilla. Generally done in children above 11
years of age.

93. 93
Some co-existing conditions which may need
repair at the time of osteotomy include:
 Palatal fistulae
 Soft tissue abnormalities
 Bone asymmetry
 Soft tissue scars of palate and lip, nose.
 Some authors are of the opinion that esthetic and
functional correction of the lip, nose or both is
best performed at a separate procedure, when
the soft-tissue and skeletal changes from
osteotomies have stabilized.

94. Prosthetic Management of Cleft Lip and
Palate Patients.
94
 When a lateral incisor is present and is viable,
every effort should be made to preserve it.
 If it is missing, orthodontic space closure may be
carried ou or space may be preserved for a future
prosthesis.
 According to Figueroa et al (Clins in Plast Surg
1993) there are certain specific indications for
prosthetic replacement of the lateral incisor.

95. 95
1. Canine on cleft side in ideal Class I relation
with lower canine.
2. Distal/ posterior eruption of the canine
3. Lack of suitable bone for tooth movement.(Give
FPD)
4. Long span of movement for canine.
5. Need for excessive palatal contouring of
canine.
6. Abnormal shape of maxillary central incisors
7. Unfavorable shape/size/ color of canine.
8. When there is sufficient bone for a single
osseo-integrated implant prosthesis.

96. References:
96
 Marazita M, Mooney M. Current concepts in the
Embryology and Genetics of Cleft Lip and Cleft
Palate. Clinics in Plastic Surgery 2004; 31(2):
125-140.
 Valiathan A, Dawoodbhoy I, Oberoi S. Incidence
of cleft lip and palate in Manipal.- A live birth
study.Journal of Pierre Fauchard Academy 1996;
10: 15-20.
 Huebner and Liu. Maxillary Orthopedics. Clinics in
Plastic Surgery 1993: 723-741.
 Johnson DD, Pretorius Dh, Budorick NE et al.
Fetal lip and primary palate: 3D versus 2D
ultrasonography. Radiology 2000;21: 236-250.

97. 97
 Johnson N, Sandy JR, Prenatal diagnosid of cleft
lip and palate. Cleft Palate and Craniofacial J
2003;40: 186-194.
 Maull D, Grayson B, Cutting C, Brecht B,
Bookstein F. Long term effects of naso-alveolar
molding on three dimensional nasal shape in
unilateral clefts. Cleft Palate and Craniofacial
Journal 1999;36(5): 391-397.
 Prahl C, Kuipers Jagtman A, Vanthoff M, Prahl
Andersen B. A randomized Prospective Clinical
trial of the Effect of Infant Orthopedics in
Unilateral Cleft Lip and Palate: Prevention of
Collapse of Alveolar segments (Dutchcleft). Cleft
Palate and Craniofacial Journal 2003; 40(4): 337-

98. 98
 Papadupoulos N, Papadopulos M, Kovacs H.
Foetal surgery and cleft lip and palate: Current
status and new perspectives. Br J Plast Surg
2005; 58:593-607.
 Grayson B, Maull D. Nasoalveolar molding for
infants born with clefts of the lip, alveolus, and
palate. Clinics in Plastic Surgery 2004;31(2): 149-
158.
 Emery and Rimoin’s Principles and Pracctice of
Medical Genetics. Rimoin, Connor, Pyeritz, Korf.
4th Edn, Churchill Livingstone, 2002.
 Orthodontics: Current Principles and techniques.
TM Graber, RLVanarsdall Jr, 4rd edn, Mosby,
2005.

99. 99
 R.E. Moyers. Handbook of Orthodontics 4th edn.
Year Book Medical publishers 1988.
 Proffit WR. Contemporary Orthodontics. 3rd
edition. Mosby, 2000.
 Wysinzski
 Berkowitz