Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Presurgical and Postsurgical Orthodontics in PatientsWith Cleft Lip and Palate

Hyoung-Seon Baik, DDS, MS, PhD

Abstract: Patients with cleft lip and palate (CLP) usually haveskeletal Class III malocclusion with maxillary deficiency due to thecleft itself and fibrous scar tissue formation caused by the recon-structive surgery. In adult CLP patients with excessive jaw dis-crepancies, orthognathic surgery is often indicated to correct theirfunctional and esthetic problems. However, CLP patients have dif-ferent inherent structures that may require a strategic approach com-pared with noncleft Class III patients. Main differences in skeletaland dental findings of lateral cephalograms between CLP and non-cleft Class III surgical patients are to be demonstrated. Furthermore,a strategic approach with various mechanics in the presurgicalorthodontic stage will be applied to suit the distinct characteristic ofthe case. Successful clinical outcome was critically dependent onthe close communication among the related specialists.

Key Words: Cleft lip and palate, presurgical and postsurgicalorthodontic treatment, skeletal Class III

(J Craniofac Surg 2009;20: 1771Y1775)

The objective of orthognathic surgery in cleft lip and palate (CLP)patients coincides to that of typical orthognathic surgery patients

in that both strive for an esthetic face and normal oral function byimproving facial skeletal and dental esthetics as well as achievingadequate functional occlusion. Successful presurgical orthodonticsis a prerequisite for successful orthognathic surgery. To accomplishthis, it is necessary to understand the skeletal and dental problemsassociated with CLP patients and consult related specialists such asorthodontists, oral surgeons, prosthodontists, and so on to establish atreatment plan. Presurgical orthodontics should be carried outaccording to the treatment plan to properly position the maxilla,mandible, and dentition during surgery.

The orthodontic dental problems in CLP patients are anteriorand/or posterior crossbite; uprighting of the upper anterior teeth,missing teeth, or supernumerary teeth in the maxilla; upper anteriorcrowding; abnormal tooth shape or size in the upper anterior teeth;and so on. The skeletal problems usually appear in the maxilla.1

MALOCCLUSION IN CLP PATIENTSPatients with CLP usually have CLP closure surgery in

infancy. The fibrous scar tissue formed by the palate surgery affectsnormal forward and downward growth of the maxilla, usually re-sulting in a vertical and horizontal maxillomandibular relationshipof skeletal Class III malocclusion with a deficient maxilla. Whencomparing the S-N-A and S-N-B angles of the Korean skeletalClass III surgical patients in a study by Baik et al2 to those of thewhite skeletal Class III surgical patients in a study by Ellis andMcNamara,2 a majority of the white sample showed an underdevel-oped maxilla, whereas most of the Korean sample showed an over-developed mandible. The same analysis was performed on CLPpatients who had received orthognathic surgery by Baik et al.3 Ac-cording to this research, skeletal Class III with underdevelopedmaxilla and a normal mandible comprised the highest percentage(55%) of CLP patients (Fig. 1). In other words, a large number ofCLP patients are skeletal Class III with underdeveloped maxilla.

Normal transverse growth of the maxilla is also affected bycleft palate closure surgery that results in constriction of the maxil-lary arch. The premaxilla appears to be narrower because of con-genitally missing teeth in the maxillary anterior cleft area (Fig. 2). Inskeletal Class III patients, dental compensation allows labial flaringof the maxillary anterior teeth, whereas in CLP patients, the max-illary anterior teeth show normal or even slight lingual crown tippingcaused by tension of the fibrous scar tissue and upper lip closure(Figs. 3 and 4). The posterior teeth are also tipped palatally (Fig. 5).

Anterior and posterior crossbite is usually observed due tomaxillary arch constriction, palatal tipping of maxillary posteriorteeth, and lingual crown tipping of maxillary anterior teeth (Fig. 4).

Missing tooth in the cleft area, peg lateral incisor or super-numerary teeth, anterior teeth rotation, crowding, and so on areobserved (Fig. 6). The lower anterior teeth are tipped lingually bydental compensation.

PRESURGICAL ORTHODONTIC TREATMENTPresurgical orthodontic treatment is a process that enables

the upper and lower teeth to occlude in the most adequate and

FIGURE 1. Comparison between noncleft Class III surgerygroup and CLP surgery group.

ORIGINAL ARTICLE

The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009 1771

From the Dental Hospital and Orthodontic Department, College of Dentistry,Yonsei University, Seoul, Korea.Received February 26, 2009.Accepted for publication April 9, 2009.Address correspondence and reprint requests to Hyoung-Seon Baik, DDS,

MS, PhD, Dental Hospital and Orthodontic Department, College ofDentistry, Yonsei University, 250 Seongsanno, Seodaemun-gu, Seoul,Korea 120-752; E-mail: baik@yuhs.ac

This article did not require any sources of funding.The authors declare that they had no financial interests or commercial

associations during the course of this study.Copyright * 2009 by Mutaz B. Habal, MDISSN: 1049-2275DOI: 10.1097/SCS.0b013e3181b5d644

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

stable position after surgery. The treatment aligns crowded teeth,coordinates the maxillary and mandibular arch, and tips the lin-gually inclined upper and lower incisors labially.

Related specialists should be consulted to either maintainthe space for further conventional prosthetic treatment or an implantor to bring the posterior teeth forward to close the space causedby the missing tooth or peg lateral incisor. Decisions are madeaccording to the patient’s condition, but it is wise to make setupmodels to verify the occlusion when resolving tooth size dis-crepancies and space problems.4

In typical skeletal Class III patients, presurgical orthodontictreatment lingually tips the upper incisors because the incisorsare flared labially. However, in CLP patients, the upper incisorsare uprighted, and labial tipping is required instead.3 The lowerincisors of CLP patients need to be flared labially as is the case intypical skeletal Class III patients to release the dental compensation(Fig. 7).

Most cases require expansion in the constricted maxillaryarch for upper and lower arch coordination. The extent of maxillaryconstriction should determine the method for maxillary expansion.A removable appliance with jackscrews or a quad-helix appliance(Fig. 8) is usually used to expand the maxillary arch in children,but it can also be applied to patients with little growth remaining incases of mild constriction.

In preadolescents or children, orthopedic expansion by rapidpalatal expansion (RPE) (Fig. 9) yields favorable results.5 However,a mini-implant reinforced RPE should be used for similar results

in adults whose midpalatal suture is fused and basal bone expansionby opening of the midpalatal suture cannot be expected with a typi-cal RPE appliance.6 Maxillary distraction osteogenesis may be usedin adult CLP patients to actually move the maxilla anteroposteri-orly with a maxillary distractor.7 This procedure can also be appliedto distract the premaxilla anteriorly, regaining space for the per-manent teeth and reestablishing normal arch form (Fig. 10).8

Generally, in CLP patients, more time is needed for this pre-surgical orthodontic procedure compared with noncleft patients.

POSTSURGICAL ORTHODONTIC TREATMENTThe purpose of postsurgical orthodontic treatment is to obtain

stable occlusion after surgery. Generally, the splint and surgical archwires are simultaneously removed, and round wires are engaged.Occlusal seating is achieved with light elastics.

Necessary prosthodontic treatment is performed after de-bonding (Fig. 11). In maxillary expansion cases, additional long-term retention appliances or prosthetic treatment is recommended

FIGURE 3. Uprighting of anterior teeth in CLP cases versuslabial tipping of anterior teeth in Class III cases.

FIGURE 4. In CLP patients (A), upper incisors are uprighted,whereas in Class III patients (B), the upper incisors areflared. Anterior and posterior crossbite is observed due tomaxillary arch constriction.

FIGURE 2. The upper arch is constricted due to fibrous scartissue in the palate.

FIGURE 5. Posterior teeth was tipped palatally as well.

Baik The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009

1772 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

because there is a higher tendency of relapse compared withnoncleft patients.

PATIENTPatient was a 21-year-old woman with left unilateral CLP and

Class III malocclusion. She had a concave facial profile, shortphiltrum, anterior and posterior crossbite with midline discrepancy,crowding in the upper and lower dentition, and severe caries in theupper left central incisor. Her lateral incisor was missing, and upperright first premolar had been extracted. Her upper arch was omegashaped (Fig. 12).7

The S-N-A angle was 73.9 degrees; A-N-B angle, wasj7.3 degrees; Wits, j6.6 mm; and mandibular plane angle,32.8 degrees, showing a hypodivergent skeletal Class III with anunderdeveloped maxilla (Fig. 13).

The upper incisors were uprighted, whereas the lower incisorswere compensated.

For presurgical orthodontic treatment, extraction of the upperleft central incisor, relief of crowding, anterior expansion and

FIGURE 6. Missing teeth are present in the cleft area alongwith crowding due to the lack of growth.

FIGURE 7. Both the compensated lower incisors anduprighted upper incisors need be flared labially.

FIGURE 8. A modified quad-helix appliance for archexpansion and labial tipping of the anterior teeth.

FIGURE 9. Rapid palatal expansion appliance.

FIGURE 10. Miniscrews were placed in the palate foranchorage reinforcement of the Hyrax (RPE) appliance.Segmentation was performed distal to the canines fordistraction osteogenesis. After 1 month, the premaxilla wasmoved anteriorly, and space was made for the ectopicallyerupted maxillary second premolar.

The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009 Pre/Postsurgical Orthodontic in CLP

* 2009 Mutaz B. Habal, MD 1773

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

posterior constriction in the maxillary arch, and decompensation ofthe lower incisors were planned. Anterior crowding was reducedby retracting the upper right canine into the extracted first pre-molar space (Fig. 14).The anterior maxillary arch was expandedwith quad helix, and posterior maxillary arch was constricted witha precision transpalatal arch simultaneously (Fig. 15).

For surgery, a 2-piece Le Fort I osteotomy, accompaniedby bone grafting, was performed on the maxilla to widen the an-terior area with forward and downward displacement. A predictionof the surgical change after maxillary 2-piece surgery was madeon a model before surgery (Fig. 16). The mandible was set backvia intraoral vertical ramus osteotomy.7

FIGURE 11. Space caused by the peg laterals was resolvedwith porcelain laminates for both lateral and central incisors.

FIGURE 12. Initial maxillary intraoral photograph. Severecaries on maxillary right central incisor, missing lateralincisor, extracted space of the left first premolar, and anomega-shaped maxillary arch are present.

FIGURE 13. Cephalometric analysis.

FIGURE 14. Quad helix is used to expand the maxillaryanterior arch, and relief of anterior crowding is donesimultaneously.

FIGURE 15. Anterior alignment is almost achieved, andthe posterior teeth are constricted with a precisiontranspalatal arch.

Baik The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009

1774 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

In postsurgical orthodontic treatment, the upper left canine wasmodified into a lateral incisor, and the first premolar into a canine byprosthodontic treatment. Due to the forward downward displace-ment of the maxilla, the philtrum and upper lip were improved(Figs. 17Y20).

For a successful orthodontic treatment, as always, accuratediagnosis, proper treatment, and good retention are important.Treatment planning for CLP patients is essential and requiresspecial attention.

It is important to consider the dental and skeletal featuresof cleft patients along with the distinct characteristics of eachpatient. In addition, interdisciplinary cooperation and care between

specialists of orthodontics, oral surgery, prosthodontics, and so onshould begin from the start of treatment planning for an estheticand functional outcome. Presurgical and postsurgical orthodontictreatment should follow this carefully planned-out blueprint.

REFERENCES1. Proffit WR, White RP, Sarver DM. Class III problems. Contemporary

Treatment of Dentofacial Deformity. Mosby Inc., 2003:543Y5552. Baik HS, Han HK, Proffit WR, et al. Cephalometric characteristics of

Korean Class III surgical patient and their relationship to plans forsurgical treatment. Int J Adult Orthod Othognath Surg 2000;15:119Y128

3. Baik HS, Yu HS, Jeon JM. A cephalometric comparison of skeletalClass III malocclusion and cleft lip and palate. Korean J Cleft Lip Palate2003;6:59Y68

4. Proffit WR, White RP. Treatment planning. Surgical OrthodonticTreatment. Mosby-Year Book Inc., 1999:625Y641

5. Baik HS. Clinical results of maxillary protraction in Korean children.Am J Orthod Dentofac Orthop 1995;108:583Y592

6. Baik HS. Limitations in orthopedic and camouflage treatment forClass III malocclusion. Semin Orthod 2007;13:158Y174

7. Baik HS, Yi CK. Surgical-orthodontic treatment in patients with cleftlip and palate. World J Orthod 2001;2:331Y340

8. Liou EJ, Chen PK, Huang CS, et al. Interdental distractionosteogenesis and rapid orthodontic tooth movement: a novel approachto approximate a wide alveolar cleft or bony defect. Plast ReconstrSurg 2000;105:1262Y1272

FIGURE 16. Amodel was used to plan the 2-piece surgery andbone grafting in the maxillary left central incisor area.

FIGURE 17. Maxillary arch after the maxillary left canine wasmodified into a lateral incisor by prosthetic treatment.

FIGURE 18. Before (A) and after treatment (B).

FIGURE 19. Superimpositions before and after surgery.

FIGURE 20. Before (A) and after treatment (B). Note theimproved concave profile.

The Journal of Craniofacial Surgery & Volume 20, Supplement 2, September 2009 Pre/Postsurgical Orthodontic in CLP

* 2009 Mutaz B. Habal, MD 1775