Treatment of cleft lip and palate (CLP) is one of the most complex, yet rewarding, challenges in our profession. It is not a sprint; it is a marathon that spans from birth to early adulthood. As orthodontists, we do not work in a silo. We are the architects within a Multidisciplinary Team (MDT) that includes oral surgeons, plastic surgeons, speech-language pathologists, ENTs, and pediatricians.
While the surgeons repair the tissues, the orthodontist’s role is to guide the underlying foundation—the bone and dental arches—to ensure that the repair looks good, functions well, and allows the child to speak clearly.
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| A multidisciplinary approach to cleft lip and palate care |
Beyond Braces: The Orthodontist as a Long-Term Partner
Our involvement begins long before the first permanent tooth erupts. In the cleft patient, the maxilla (upper jaw) is often segmented, collapsed, and growth-restricted due to scar tissue from early surgeries. The orthodontist’s primary goal is to normalize the dental arch form to facilitate surgical closure and allow for normal speech and chewing.
Clinical Milestones: The Roadmap of Care
Successful management of CLP relies on doing the right thing at the right time. Intervening too early can hamper growth; intervening too late can compromise the result. Here is the standard timeline of orthodontic intervention:
1. Infancy (0 – 12 Months): The Foundation
Objective: Reduce the severity of the cleft deformity before the primary lip repair.
Intervention: Presurgical Infant Orthopedics (PSIO) or Nasoalveolar Molding (NAM).
Action: We use passive appliances to approximate the cleft lip and alveolar segments and mold the flattened nose. This reduces tension on the surgical site, leading to better esthetics and less scar tissue.
2. Primary Dentition (2 – 6 Years): The Observation Phase
Objective: Monitor growth and speech.
Intervention: Usually minimal.
Action: Unless there is a functional shift of the jaw (a severe crossbite causing the jaw to slide), we often wait. This preserves the cooperation of the young child for the more critical phases ahead.
3. Early Mixed Dentition (7 – 9 Years): The Critical Turning Point
Objective: Prepare the maxilla for the Secondary Alveolar Bone Graft (SABG).
Intervention: Maxillary Expansion (Quad Helix or RME).
Action: The maxillary segments are often collapsed. We must expand the upper jaw to align the segments and create a bed for the surgeon to place the bone graft.
Timing is Key: This must be done before the permanent canine erupts, so the canine can erupt naturally into the newly grafted bone, ensuring periodontal health.
4. Permanent Dentition (12 – 16 Years): Comprehensive Alignment
Objective: Establish functional occlusion and smile esthetics.
Intervention: Fixed Mechanotherapy (Braces).
Action: We align the permanent teeth, correct rotations common in the cleft area, and manage missing teeth (often the lateral incisor) by either closing the space or preparing it for a future implant.
5. Skeletal Maturity (17+ Years): The Final Polish
Objective: Correction of skeletal discrepancies.
Intervention: Orthognathic Surgery.
Action: Many cleft patients have a maxilla that does not grow forward enough (Class III skeletal pattern). Once growth is complete, we work with surgeons to advance the upper jaw (Le Fort I osteotomy) to achieve the final facial profile and bite.
Conclusion
The management of cleft lip and palate is a testament to the power of collaboration. As orthodontists, we are privileged to watch these patients grow from infants into confident young adults. It is our precise management of the hard tissues that allows the soft tissue work of our surgical colleagues to truly shine.
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