Experts Corner

Orthodontic management of patients with cleft lip

and palate

Pradip R. Shetye Abstract

Department of Plastic Surgery,
New York University Langone The management of patients with cleft lip and cleft palate requires prolonged orthodontic
Medical Center, New York, and surgical treatment and an interdisciplinary approach in providing them with
NY 10016, USA optimal esthetics, function, and stability. This paper describes an update on the current
concepts and principles in the treatment of patients with cleft lip and palate. Sequencing
and timing of orthodontic/orthopedic and surgical treatment in infancy, early mixed
dentition, early permanent dentition, and after the completion of facial growth will
be discussed.
Key words: Cleft lip and palate, nasoalveolar molding, secondary alveolar bone
graft

INTRODUCTION of overall team management. The goal for the complete

rehabilitation of patients with clefts is to maximize
Cleft lip and palate is the most frequently occurring treatment outcome with minimal interventions.
congenital anomaly. Depending on the extent of the
cleft defect, patients may have complex problems In a patient with cleft lip and palate, the orthodontic
dealing with facial appearance, feeding, airway, hearing, malocclusion can be related to soft tissue, skeletal or dental
and speech. Patients with cleft lip and palate are ideally defects. Some cleft orthodontic problems are directly
treated in a multidisciplinary team setting involving related to the cleft deformity itself, such as discontinuity
specialties from the following disciplines: Pediatrics, of the alveolar process, and missing or malformed teeth,
plastic and reconstructive surgery, maxillofacial surgery, whereas other aspects of the malocclusion are secondary
otolaryngology, orthodontics, genetics, social work, to the surgical intervention performed to repair the lip,
nursing, speech therapy, pediatric dentistry, prosthetic nose, alveolar and palatal defects. A malocclusion may
dentistry, and psychology. The orthodontic and surgical exist in all the three planes of space: Anteroposterior,
treatment of patients with clefts is extensive, initiating at transverse, and vertical. The malocclusion may reflect
birth and continuing into adulthood when craniofacial the severity of the initial cleft deformity and the growth
skeletal growth is finished. The role of the orthodontist response to the primary surgery. As malocclusion in
in timing and sequence of treatment is important in terms patients with clefts is often a growth‑related problem, the
effect of the cleft deformity and primary surgery will be
Access this article online observed throughout the growth of the child until skeletal
Quick Response Code: maturity. The orthodontist must make critical decisions
Website: for orthodontic intervention at the appropriate time and
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prioritize treatment goals for each intervention. For the

DOI:
10.4103/2321-1407.194790 This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.

Address for Correspondence: For reprints contact: [email protected]

Asst. Prof. Pradip R. Shetye, Department of Plastic Surgery,
New York University Langone Medical Center,
307 East 33rd Street, New York, NY 10016, USA. How to cite this article: Shetye PR. Orthodontic management of
E‑mail: [email protected] patients with cleft lip and palate. APOS Trends Orthod 2016;6:281-6.

© 2016 APOS Trends in Orthodontics | Published by Wolters Kluwer - Medknow 281

 Shetye: Orthodontic treatment for patients with clefts

purpose of the organization, the orthodontic treatment alignment of the alveolus, lip, and nose helps the
of patients with clefts will be presented in four distinct surgeon achieve a better and more predictable surgical
treatment phases: Infancy, primary dentition, mixed result.[3] Long‑term studies of NAM therapy indicate
dentition, and permanent dentition. that the change in nasal shape is stable.[4] The improved
quality of primary surgical repair reduces the number of
surgical revisions, oronasal fistulas, and secondary nasal
TREATMENT DURING INFANCY and labial deformities.[4‑8] If the alveolar segments are
in the correct position and a gingivoperiosteoplasty is
Presurgical infant orthopedics has been used in the performed, the resulting bone bridge across the former
treatment of cleft lip and palate patients for centuries. In cleft site improves the conditions for the eruption of the
1993, Grayson et al. described a new technique, nasoalveolar permanent teeth and provides them with better periodontal
molding (NAM), to presurgically mold the alveolus, lip, and support. Studies have also demonstrated that 60% of
nose in infants born with cleft lip and palate.[1] patients who underwent NAM and gingivoperiosteoplasty
did not require secondary bone grafting[9] [Figure 2]. The
The initial impression of the infant with cleft lip and palate
remaining 40% who did need bone grafts showed more
is obtained within the 1st week after birth using a heavy bone remaining in the graft site compared to patients who
body silicon impression material, and the NAM appliance is had not had gingivoperiosteoplasty.[10]
inserted within the first 2 weeks. The NAM appliance has two
components—the oral (molding plate) and the nasal (nasal
stents). The oral component molds the clefted alveoli in TREATMENT DURING THE PRIMARY
order to allow them to approximate each other. The nasal DENTITION
components mold the distorted nasal cartilage on the clefted
nose, making it more symmetrical [Figure 1]. Nasal molding The treatment goals during the primary dentition stage
helps expand the tissue of the mucosal lining of the nose. In of development focus on the acquisition of normal
unilateral cleft patients, the nasal stent straightens the deviated speech function, which is managed by a speech therapist
columella toward the noncleft side. In patients with bilateral or pathologist and the surgeon. During this phase, the
cleft lip and palate, the nasal stent elongates the deficient patient is closely monitored by the speech and language
columella by gradually stretching the columella tissue. With therapists. Patients may or may not need speech therapy
the help of tape, the lips also are molded to reduce the size depending on the diagnosis of speech issues. If the child
of the cleft. This process is done over a 3–4‑month period has been diagnosed with velopharyngeal insufficiency, then
and with active involvement by the family in the NAM the surgeon may perform a pharyngeal flap. This surgery
process. A recent study of caregivers demonstrated that is typically performed around age 2.
NAM was often associated with positive factors for parents
such as increased empowerment, self‑esteem, and bonding Another important component of care for a patient
with their infant.[2] After completion of NAM treatment, the during this time period includes routine follow‑up with
infant is then referred to the surgeon for primary closure of
lip, nose, and alveolus.

There are several benefits with the NAM technique in

the treatment of cleft lip and palate deformity. Proper

a b Figure 2: Sectional cone‑beam computed tomography of a patient who

Figure 1: (a) Bilateral nasoalveolar molding plate with the nasal underwent nasoalveolar molding and gingivoperiosteoplasty surgery
stents in placed (b) In a patient with bilateral cleft, a prolabial tape to repair the alveolus at the time of primary lip closure. Note good
adhered to the prolabium and attached to the molding plate with bone formation on the right former cleft side. This patient did not need
tension secondary alveolar bone graft surgery

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 Shetye: Orthodontic treatment for patients with clefts

a pediatric dentist. Regular visits to the pediatric dentist To provide the most stable environment for integration
every 6  months are strongly recommended to prevent of the alveolar bone graft and the maintenance of palatal
dental caries. expansion, we routinely place an occlusally bonded acrylic
or removable Tru‑Tain type splint at the time of surgery.
The splint serves to immobilize the alveolar segments
TREATMENT DURING MIXED DENTITION as well as to prevent relapse of presurgical maxillary
expansion. The splint remains in place for 6–8  weeks
The treatment objectives for a child as he/she enters
postsurgery.
mixed dentition are directed toward preparing the patient
for secondary alveolar bone graft  (SABG) surgery. The The management of a bilateral cleft lip and palate patient
alveolar bone graft surgery is typically performed around may pose a unique challenge with respect to the position
8–9 years of age. A limited volume cone‑beam computed of the premaxilla before bilateral alveolar bone grafts.
tomography (CBCT) performed at this age is invaluable to However, if the premaxilla is ectopically positioned, the
identify the cleft defect and the position of the permanent patient may need premaxillary repositioning surgery.
teeth adjoining the cleft defect. The principal benefits of The presurgical expansion is preformed to improve the
alveolar bone grafting are: (1) To provide sufficient bone arch form before surgery. A bonded occlusal splint is
for the eruption of either the maxillary lateral incisor constructed after model surgery. In the operating room,
or canine, (2) to provide adequate bone and soft‑tissue the surgeon uses the splint to reposition the premaxilla and
coverage around teeth adjacent to the cleft site,  (3) to perform the SABG surgery.
close the oronasal fistulae to prevent nasal air escape and
fluid or food leakage,  (4) to provide additional support Six months after SABG surgery, a postoperative CBCT
and elevation to nasal structures, (5) to restore the alveolar must be obtained to confirm the outcome of SABG surgery
ridge in the area of the cleft, thereby allowing orthodontic [Figure 4]. After successful repair of the cleft defect, the
tooth movement and future placement of dental implants, patient can then start Phase I fixed appliance treatment to
and (6) to stabilize premaxillary segments in patients with correct malpositioned anterior teeth. If a patient shows
bilateral clefts. a skeletal crossbite, manifested as negative overjet at this
stage, protraction headgear treatment can be initiated for
Discrepancies in maxillary arch form or transverse width about 9 months to correct the skeletal crossbite.
should be improved before the SABG. It is of note that
the surgeon and orthodontist must work in tandem to
determine the anatomical limits of presurgical maxillary TREATMENT DURING PERMANENT
expansion. This is imperative, as overexpansion may create DENTITION
an oronasal fistula or a defect that is beyond the limits of
surgical closure [Figure 3]. Lateral cephalometric growth studies have shown that the
maxilla in treated patients with cleft lip and palate show

a
a

b
Figure 3: Sectional cone‑beam computed tomography of pre‑ and b
post‑alveolar bone graft sites. (a) Note the large alveolar defect on Figure 4: Occlusal (a) and frontal (b) views of a patient with bilateral
the lateral wall of the maxillary left central incisor. (b) The postalveolar cleft lip and palate who underwent rapid maxillary expansion with a
bone graft sectional cone‑beam computed tomography shows good bonded acrylic fan expander. Following transverse expansion, patient
bone formation of the alveolar cleft site 6 months postiliac bone graft had bilateral alveolar bone grafts and premaxillary repositioning

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 Shetye: Orthodontic treatment for patients with clefts

variable degrees of maxillary hypoplasia. The reasons crossbites can be corrected with an advancing arch wire
for abnormal facial morphology in treated cleft patients and posterior crossbite with archwire expansion or with a
may involve intrinsic skeletal and soft tissue deficiencies, removable quad helix.
iatrogenic factors introduced by treatment, or a combination
of both. At birth, cleft lip and palate deformities vary There are two options regarding management of a
greatly in severity. In some patients, there may be adequate missing lateral incisor: Either maintenance of the space
tissue volume, but the cleft segments have failed to fuse for a dental implant or movement of the canine into the
together due to inadequate cell migration. In others, there lateral incisor space, recontouring it to resemble a lateral
may be varying amounts of missing tissue (bone, soft incisor. If the decision is made to maintain space for a
tissue, and teeth) associated with nonfusion of the cleft dental implant, optimal space must be made available for
segments. Both groups of patients may respond differently the implant to replace the missing lateral incisor. During
to surgical treatment. active orthodontic treatment, this space can be maintained
with the use of a pontic tooth that contains a bracket and
Clinically, patients with clefts may present with a concave is ligated to the orthodontic archwire. At the conclusion
profile, midface deficiency, and a Class III skeletal pattern. of treatment, a cosmetic removable prosthesis should be
The maxilla may also be deficient in transverse and vertical fabricated to maintain the space. Once craniofacial skeletal
planes, contributing to posterior skeletal crossbite and growth is complete, a single tooth implant can be placed.
reduced midface height. Dentally, there may be lingually
inclined incisors and constricted maxillary posterior arch If canine substitution is planned for replacement of
width, causing anterior or posterior crossbite. The extent the missing lateral incisor, then several canine crown
of abnormal midface growth may vary from mild to modifications are needed to achieve optimal esthetics. The
severe. The severity distribution of abnormal midfacial permanent canine will need recountering on incisal, labial,
growth is concentrated in the center of the bell curve, mesial, distal, and lingual surfaces. Recontouring can be
whereas patients with good growth and severe growth done progressively during active orthodontic treatment.
disturbances are dispersed on either side of the curve.[11] When bonding this tooth, a lateral incisor bracket will be
Depending on the severity of the malocclusion presented placed more gingivally, to bring its gingival margin down to
by the cleft patient, the management can be categorized the level of the adjacent central incisor. The first bicuspid
into three types. In the first category, the patients have no will then take the canine position and will also need
skeletal discrepancy and orthodontic correction is limited reshaping to resemble a permanent canine. The second
to tooth movement only. In the second category, there is premolar and first and second molars are moved mesially.
a mild skeletal discrepancy and the patients will benefit The patient’s orthodontic treatment is completed with a
from camouflaging the malocclusion by orthodontic tooth Class II occlusal relationship on the side of the missing
movement alone. In the last category of patients, there is lateral incisor. With successful esthetic bonding, excellent
moderate to severe skeletal deformity, and optimal results results can be achieved with this option.
can only be obtained by combined surgical/orthodontic
intervention. It is important to establish as early as possible Patients with mild skeletal discrepancy
if the patient will be treated with orthodontics alone or In patients presenting with mild skeletal discrepancy and
orthodontics in conjunction with surgery. The direction of minimal esthetic concern, orthodontic dental compensation
orthodontic tooth movement to camouflage a very mild may be recommended. A thorough clinical exam, growth
midface deficiency is opposite to that of tooth movement status and stature, hand‑wrist films, and serial cephalometric
required to prepare a patient for midface advancement assessments need to be performed before suggesting this
surgery. option. However, the patient and the family should be
cautioned that the outcome can be compromised if the patient
Patients with no skeletal deformity outgrows the dental compensation and ultimately may need
If a cleft patient in permanent dentition presents with no extended orthodontic treatment to remove the compensations
skeletal deformity (anteroposterior transverse or vertical), and prepare for orthognathic surgery. Proclination of the
then the management of the dental malocclusion does maxillary incisors and lingual inclination of the lower incisor
not differ very much from that of the noncleft patient. can adequately camouflage a mild skeletal discrepancy.
Patients with isolated clefts of the lip and alveolus or
clefts of the soft palate may fall into this group and will Patients with moderate to severe skeletal discrepancy
benefit from fixed orthodontic treatment alone. The dental Patients presenting with moderate to severe skeletal
malocclusion may be limited to mild dental anterior or discrepancy may achieve the best esthetic and functional
posterior crossbites, rotated and malposed teeth, and results through a combination of orthodontic treatment
missing the lateral incisor in the cleft area. Mild anterior that is carefully coordinated with orthognathic surgery.

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 Shetye: Orthodontic treatment for patients with clefts

Depending on the severity of the skeletal discrepancy, that the patient may outgrow the surgical orthodontic
the patient may require only maxillary advancement or a correction and may need another corrective surgery
combination of maxillary advancement and mandibular on the completion of skeletal growth. In these cases,
setback. If the surgical/orthodontic option is elected, distraction osteogenesis may be considered as an
timing of the orthodontic and surgical treatment becomes alternative. The advantages of distraction osteogenesis
critical [Figure 5]. in a growing patient with cleft lip and palate include the
generation of new bone at the site of the osteotomy,
Under optimal conditions, it is recommended to remove all large advancement without the need for a bone graft,
dental compensations and to align the teeth in an optimal and gradual stretching of the scared soft tissue. Since
position relative to the skeletal base and alveolar processes. distraction osteogenesis and midface advancement
The orthodontist will plan the coordination of maxillary and are performed at the rate of 1 mm/day, changes in
mandibular arch widths by hand articulating the progressing velopharyngeal competence can be monitored during
dental study models into the predicted postsurgical the advancement. For the skeletally mature cleft patient
occlusion. Once the presurgical orthodontic treatment goals who shows a severe maxillary deficiency, advancement
are achieved (coordinated maxillomandibular arch width, of the midface with distraction osteogenesis is also a
compatibility of occlusal plans, satisfactory intercuspation), good treatment option [Figure 6].
the patient may be debonded and placed on removable
retainers until craniofacial skeletal growth is complete. This Distraction in the cleft patient can be achieved with
assessment is made by observation of the closing sutures in external or internal distraction devices. Depending on
the hand‑wrist radiographs, by measurements of mandibular the surgeon’s preference and clinical presentation of
body length in serial lateral cephalograms and measurements deformity, either approach may be used to achieve the
of change in stature or height. The patient is placed on desired results. Internal distraction devices are more
fixed orthodontic appliances for a short, presurgical acceptable to the patient; however, they offer some clinical
orthodontic treatment phase before orthognathic surgery. limitations. The external devices can be adjusted to change
The combined surgical and orthodontic treatment goals are the vector of skeletal correction during the active phase
planned in close coordination with the surgeon. After the of distraction while the internal device cannot be adjusted
surgical correction is completed, a 12‑month postsurgical in this way. After the Le Fort I osteotomy and a latency
orthodontic phase of treatment begins. The objectives period of 5–6 days, the distraction device is activated at
of postsurgical orthodontics are to balance the forces of the rate of 1 mm/day until the desired advancement is
skeletal relapse with intermaxillary elastics, to observe the achieved. Interarch elastics may be used during the active
skeletal stability of the surgical correction, and to detail the phase of distraction osteogenesis to guide the maxilla to
postsurgical occlusion. its optimal position and the teeth to optimal occlusion. On
completion of the advancement, there is an 8‑week period
Sometimes, a maxillomandibular skeletal discrepancy of bone consolidation during which time the distraction
is severe, and for psychosocial reasons, early surgery devices serve as skeletal fixation appliances. Following
during the mixed or permanent dentition is indicated. this period of bone healing, the distraction devices are
However, the patient and their family must be cautioned removed, and postdistraction orthodontics begins. The
objective of postdistraction orthodontics is to retain the
position of the advanced midfacial skeleton and to fine
tune the occlusion.

Figure 6: Series of patients treated for Le Fort I midface advancement

Figure 5: Bilateral cleft patient with two-jaw surgery. Lateral with internal distraction: Lateral cephalograms before, during, and after
cephalogram pre- and post-surgery internal midface distraction

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 Shetye: Orthodontic treatment for patients with clefts

CONCLUSION Broder HL, et al. Assessment of presurgical clefts and predicted

surgical outcome in patients treated with and without nasoalveolar
molding. J Craniofac Surg 2015;26:71‑5.
The successful management of a patient with cleft lip 4. Maull  DJ, Grayson  BH, Cutting  CB, Brecht  LL, Bookstein  FL,
and palate requires careful coordination of all members Khorrambadi  D, et al. Long‑term effects of nasoalveolar molding
of the cleft palate team. The introduction of NAM has on three‑dimensional nasal shape in unilateral clefts. Cleft Palate
Craniofac J 1999;36:391‑7.
significantly changed the outcome of cleft treatment. The 5. Cutting  C, Grayson  B, Brecht  L, Santiago  P, Wood  R, Kwon  S.
shape, form, and nasal esthetics of patients with clefts are Presurgical columellar elongation and primary retrograde nasal
significantly better in those who have had the benefits of reconstruction in one‑stage bilateral cleft lip and nose repair. Plast
Reconstr Surg 1998;101:630‑9.
NAM. Clinical techniques constantly will be improved to 6. Pfeifer  TM, Grayson  BH, Cutting  CB. Nasoalveolar molding and
enable the clinician to provide the best possible care while gingivoperiosteoplasty versus alveolar bone graft: An outcome
striving to reach the goal of excellent facial esthetics in analysis of costs in the treatment of unilateral cleft alveolus. Cleft
patients born with clefts. Palate Craniofac J 2002;39:26‑9.
7. Patel  PA, Rubin  MS, Clouston  S, Lalezaradeh  F, Brecht  LE,
Cutting  CB, et al. Comparative study of early secondary nasal
Financial support and sponsorship revisions and costs in patients with clefts treated with and without
Nil. nasoalveolar molding. J Craniofac Surg 2015;26:1229‑33.
8. Lee  CT, Grayson  BH, Cutting  CB, Brecht  LE, Lin  WY. Prepubertal
Conflicts of interest midface growth in unilateral cleft lip and palate following alveolar
molding and gingivoperiosteoplasty. Cleft Palate Craniofac J
There are no conflicts of interest. 2004;41:375‑80.
9. Santiago  PE, Grayson  BH, Cutting  CB, Gianoutsos  MP, Brecht  LE,
Kwon SM. Reduced need for alveolar bone grafting by presurgical
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