Children born with Cleft lip and palate have a number of problems that have to be solved for successful rehabilitation. Cleft lip and palate is commonly associated with dental problems like neonatal tooth, congenitally absent tooth, various anamolies of tooth morphology, premature loss of tooth adjacent to cleft, rotated tooth adjacent to cleft, cross bite due to medial collapse of maxilla etc. Orthodontia plays a vital role in managing the above mentioned problems.

Orthodontic Management of cleft lip and palate can be conveniently divided into four stages.

Stage I

(maxillary orthopaedic stage-birth to 18 months)

The treatment modalieies carried out during the first stage include Fabrication of a passive obturator, Presurgical Orthopaedics.

Passive maxillary obturator:
The maxillary obturator is an intra-oral prosthetic device that fills the palatal cleft and thus provides false roofing against which the child can suckle. It thus reduces the incidence of feeding difficulties such as insufficient suction, excessive air intake and chocking. IT also provides maxillary cross arch stability preventing the arch from collapsing.

The obturator is fabricated using cold pure acrylic after selective blocking of all undersirable undercuts. Clasps can aid in retention. In case of insufficient retention, wings made of thick wire can be embedded in the acrylign and made to follow the cheek contour extraarally. These wings can be stabilized against the cheeks using micropore adhesive tape.

Presurgical Orthopaedics:
The aim of presurgical orthopaedics is to achieve an upper arch form that conforms to the lower arch. The absence of variable amount of lip tissue and the division in the alveolus and the palate results in forward siaplacement of the premaxilla (in case of bilateral clefts) or the greater segment (incase of unilateral clefts). The orthodontist should try to correct these displacement by extraoral strapping across the premaxilla, attached directly to the face or to some form of head cap. A micropore adhesive tape can also be strapped across the premaxilla. Incase of a narrow, collapsed maxillary arch, the expansion can be achieved by a suitable appliance incorporating expansion screws of springs.

The advantages of presurgical orthopaedic phase are; It reduces the size of the cleft there by aiding in surgery, Partial obturation of the cleft assist feeding, Improved speech as size of the defect is reduced, It reassures the parents at a crucial time.

Stage 2

This comprises the treatment carried out during the primary dentition. The procedures carried out during this phase are

      1. Adjustments in the intro oral obturator to accommodate the erupting deciduous tooth.
      2. To maintain a check on eruption pattern and timing.
      3. Oral hygiene instructions.
      4. Restoration of decayed tooth.

No orthodontic treatment is usually initiated during this phase as the benefits desired would be lost as soon as the deciduous teeth are shed.

Stage 3

This includes treatment carried during the mixed dentition phase. The orthopaedic procedures usually carried out are

      1. Correction of anterior crossbites using removal or fixed appliances. The anterior cross bites should be corrected to avoid functional mandibular displacements and retardation of maxillary growth due to lock in maxilla. Removal appliances incorporating Z spring fan be used to treat the anterior cross bite.
      2. Buccal segment crossbites are also treated using quadhelix or expansion screws.

Stage 4

This stage consist of treatment during the permanent dentition. The patient is treated using fixed orthodontic appliances. All local irregularities like crowding, spacing, crossbites and overjet / overbite problems are corrected. Patients with hypoplastic maxilla may be given face mask to advance the maxilla. Prosthesis can be given in the case of missing teeth after completion of orthodontic therapy.

Following the orthodontic treatment procedures, the patient should be put on a retention phase to maintain the orthodontic corrections. Most cleft lip and palate cases require long term if not permanent retention for the following reasons.

      1. Inadequate bone support
      2. Absence of some teeth
      3. Presence of stretched scar tissue

The key to the successful rehabilitation cleft lip and palate cases includes flexibility and a multidisciplinary approach. More than this the patient should be treated with sympathy and concern