Multidisciplinary Treatment of Cleft Lip/Palate Including

Secondary Bone Grafting

Dr. Michael S. Cooke
PhD, BchD, FDS, FFD, DOrth
Senior Lecturer in Orthodontics
Department of Children's Dentistry and
Orthodontics
University of Hong Kong
Summary
The multi-discipline "team"* approach for the
care of cleft patients is outlined and a typical
overall sequence of treatment presented.
A case is described which emphasises the final
dental/orthodontic/surgical procedures including
the new technique of secondary alveolar bone
grafting into the cleft area. By preventing the usual
dental arch "spacings" and the need for dental
prostheses, better long term results can now be
achieved.
Introduction
The comprehensive treatment of patients born
with complete clefts of the lip and palate brings
together many disciplines. Best long-term results are
achieved under the guidance of a cleft "team" which
regularly consults and which plans a specific
sequence of care, for each patient, under the overall
direction of a team leader, usually the Plastic
Surgeon or the Orthodontist*.
A principle complaint of treated cleft patients
concerns the final dental appearance1. Anterior
spaces remaining in the upper dental arch are
usually unavoidable as teeth are commonly missing
in the cleft area or are unable to erupt due a
deficiency of alveolar bone. Prosthetic replacement
of the missing teeth, which may itself lead to future
problems, is therefore usually undertaken in the late
teenage years.
A recent development, which prevents the need
for a dental prosthesis, is the secondary grafting of
* A multidisciplinary team, led by a Paedodontist, is currently functioning within the Department of Children's Dentistry and Orthodontics,
University of Hong Kong.
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bone into the cleft area2-5, 7. The erupting canine is
then able to erupt through the new bone and
establish a continuous dental arch without spacings.
The final dental result both short term and long
term is thereby much improved functionally and
aesthetically.
This paper outlines typical "team" care for a cleft
patient and then describes the oral care for a patient
believed to be the first in Hong Kong to receive a
secondary alveolar bone graft.
The Cleft "Team"
Plastic Surgeon
To repair clefts of the lip and palate, reposition
the anterior segment in bilateral cases and deepen
the labial sulcus. Improve the function of the soft
palate and later improve the aesthetics of lip and
nose. Serve as parent figurehead and team co-
ordinator.
Paedodontist
To construct feeding plates and offer advice to
parents on feeding techniques for the new-born.
Supervision of healthy dental state with emphasis on
prevention. Dietary advice and possibly regular
fluoride applications.
E.N.T. Surgeon
To perform aural examination and hearing tests
to ensure that the child has adequate hearing so that
he may communicate and learn. Surgical procedures
may be necessary.
Orthodontist
To fit appliances which mould the cleft segments
into better alignment in order to make surgery
easier ( "pre-surgical orthopaedics"). To correct
minor tooth irregularities in the mixed dentition and
later, in the permanent dentition, to correct the
overall crowding, alignment, and occlusion of the
teeth.

Speech Therapist
To advise parents on communication problems
and to aid speech. The direct effect of the cleft
palate is to produce hypernasality, nasal function
and defective articulation due to the inability to
build up sufficient pressure in the mouth. They may
also have speech problems unrelated to the cleft,
e.g. poor language development or a stammer.
Psychologist and Social Worker
To advise and support parents. Many parents feel
guilt and shame and some mothers initially reject
their baby. As family life is often disrupted when
these children visit hospitals for operations,
consultations etc. social workers may be able to
offer a "back-up".
The patient may develop personality problems
associated with the deformity. A psychologist may
be required to counsel the adolescent as they
develop an awareness that they are different from
their friends.
At a later stage (later teenage years) cleft
patients usually have an underdeveloped maxilla
(due primarily to earlier surgery producing scarring
which interferes with forward maxillary growth) and
severe problems with the permanent dentition6. At
this later stage the cleft team would also include an
Oral Surgeon (to restore the occlusion and the
skeletal balance of the profile), a Prosthodontist
and a Restorative Dentist (to maintain the dental
arch "expansion" usually produced by the
Orthodontist, to fill spacings between the teeth and
to improve the dental aesthetics).
A typical example of overall case management is
now presented, followed by a case which illustrates
the later dental stages, including secondary alveolar
bone grafting.
Case Management
BIRTH Child is referred to a Plastic
Surgeon. Paedodontist may construct
a feeding plate and initiate
presurgical dental orthopaedics.
Team members, a Paediatrician
and/or a Dietician should advise the
parents of the need for adequate
Vol. 11 No. 3 March 1989
weight gain. This prevents any
feeding problems so the child can
attain the necessary stage of
development prior to surgery.
3 MONTHS Surgical repair of lip. Timing of
surgery does vary. Bilateral cases
may have a two stage procedure.
6 MONTHS Begin preventive dentistry.
15 MONTHS Surgical repair of the palate. A
large defect may be repaired in two
stages.
Speech Therapist checks progress.
The child should be able to say a
few words. Listening and
comprehension tests may be needed.
2 YEARS Plastic Surgeon assesses the result of
surgery.Orthodontist examines the
teeth and soft tissues to assess the
position of the anterior segment and
the depth of the upper labial sulcus.
E.N.T. Surgeon checks the child's
hearing and examines the tympanic
membrane.
Speech Therapist gives advice and
listens to the child's speech.
He should now be joining words
together and have a vocabulary of
about 50 words.
Paedodontist stresses the importance
of dental health.
3 YEARS Plastic Surgeon checks appearance
and function at yearly intervals from
now on. Regular dental checkups
from Paedodontist at four monthly
periods.
4 YEARS Audiogram and compliance tests are
performed and if necessary a
grommet is placed in the ear drum.
The child should now have a large
vocabularly and good sentence
construction. If necessary speech
therapy is started.
5 YEARS X-ray examination to assess tooth
development.
7 YEARS At the age of 7 years, approximately,
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Multidisciplinary Treatment of Cleft Lip/Plate

the levator palati muscle takes over The aims of this procedure are to normalize the
from the tensor palati in being the alveolar process anatomy and to achieve a
muscle most responsible for opening continuous dental arch by permitting the eruption of
the eustachian tube and hearing the canine through bone into arch alignment.
problems may disappear. Additional benefits include bony support for the
Correction of malalignment of the adjacent teeth and for the nasal alar base and the
anterior teeth and labial segment opportunity to close persistent oro-nasal fistulas.
relationship.
During surgery3'7 the soft tissues lining the defect
9 YEARS Surgery to improve the appearance are usually elevated and everted to form a nasal
of the lip and nose. Secondary floor. After packing bone into the cleft a sliding
alveolar bone grafting considered to periodontal flap is sutured to cover the defect. A
permit eruption of canine and thereby flap from the cheek may occasionally be necessary.
avoid future gaps in the dental arch.
11 YEARS Correction of the malocclusion. CASE WWA
A further course of orthodontic
therapy is usually needed to correct WWA presented as an 8-year old Chinese girl
the crowding and malalignment of with repaired unilateral (left) complete cleft of lip
the dental arches. and palate. Her dental appearance is shown in
Arch expansion is often attempted, Figure 1. The chief complaint was the poor
the incisors aligned and usually space
is created for the eventual
prosthodontic treatment of malformed
and congenitally missing teeth.
16 YEARS Surgery to improve the appearance
of the nose and lip. Oral Surgeon
assesses the profile. A Le Fort 1
maxillary osteotomy is often
considered to correct the retrusion
which is common in cleft cases.
Replacement of missing teeth by a
bridge or denture.

Secondary Alveolar Bone Grafting

Bone grafting in infants (primary bone grafting)
and in early childhood (early secondary bone
grafting) had previously been advocated but long
term results have been poor with subsequent growth
disturbances to the maxilla6. These techniques have
been generally abandoned.
Recently several follow-up reports have described
successful results with later grafting of autogenous
iliac crest bone (as cancellous particulate bone) into
the alveolar cleft defect. These grafts were Figure 1: Anterior (a) and upper occlusal (b)
completed between 6-12 years with best results dental views at age 8 years. The patient
among patients operated on before the beginning of was complaining of the rotated teeth
eruption of the permanent canine tooth2-5. and the "incorrect" bite.

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Multidisciplinary Treatment of Cleft Lip/Plate
alignment of her upper anterior teeth and the
"incorrect" bite, with the lower teeth over-closing in
front of the uppers.
The upper left lateral incisor was missing, the
upper right lateral incisor blocked out of line and
the upper central incisors severely rotated. Further
typical "cleft" features included the presence of some
malformed primary teeth in the cleft area.
A preventive based programme of general dental
Figure 2: Upper anterior occlusal radiographs
(age 10-years) showing a) the upper left
cleft area with the unerupted left canine
(the orthodontic appliance can also been
seen); and b) the end of treatment
dental alignment (age 12-years) with no
visible alveolar cleft and well aligned
upper teeth. The screws are part of the
post-surgical maxillary fixation.
130
care was commenced followed at age 10 years by the
fitting of fixed orthodontic appliances. The
radiograph at this stage (Figure 2a) shows the cleft
area devoid of alveolar bone and with the upper left
canine lying unerupted.
Autogenous cancellous bone chips derived from
the iliac crest were grafted, sub-periosteally, into the
alveolar defect both to restore the alveolar ridge
anatomy and in the hope that the canine would
erupt through this transplanted bone into arch
alignment. At surgery the misplaced upper right
lateral incisor was extracted and also the malformed
teeth in the cleft line.
By age 12-years the canine had fully erupted and
both upper and lower arches had been well aligned.
The maxilla remained diffident anteroposteriorly
(Figure 3a) with the lower teeth biting in front of
the uppers. Surgery to move the maxilla forwards
into a normal position of facial balance (A Le Fort
2 level osteotomy supported by bone grafts and
osteogenic bone plating fixation) was next completed
(Figure 4) followed by a second final phase of
orthodontics to idealize the occlusion. The
orthodontic archwires were used for part of the
post-surgical fixation.
Finally the pointed upper canines were modified
in shape using new tooth coloured materials in
order to have them mimic the missing square
shaped upper lateral incisors (Figure 5a). As the
long term stability of the anterior teeth is uncertain
a flexible wire was "bonded" to the palatal aspects of
the anterior teeth to provide long term stability. The
flexibility of the wire allows physiologic movements
of the splinted teeth during function (Figure 5b).
The final dental appearance is shown in Figure 5
and the radiograph in Figure 2b. Figure 4 shows the
extent of the maxillary forward movement and its
effect on the profile. In life, the smile line of the
upper lip is low and does not permit the uneven
levels of the gingiva around the teeth necks to be
noticed.
Acknowledgements
Thanks to Dr. Gordon Ma (formerly Consultant
Plastic Surgeon at Princess Margaret's Hospital,
Hong Kong) for performing the secondary bone
 Vol. 11 No. 3 March 1989

Figure 3: Anterior lateral views before (a) and after (b) the forward surgical maxillary movement. The initial
"reverse" bite has been corrected and the fixed orthodontic appliance removed.

Figure 4: Lateral skull radiographic tracings showing the type and extent of the Le Fort 2 maxillary surgical
advancement. The profile changes are also shown.

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Multidisciplinary Treatment of Cleft Lip/Plate

Figure 5: End of treatment anterior (a) and occlusal (b) views showing the dental appearance after
reshaping the "pointed" canines to mimic "square" lateral incisors and after bonding the flexible
splinting wire palatally. A contiguous dental arch has been produced with no spacings or
prosthesis. (The diffuse white opacities are developmental defects of the enamel.)

Boyne PJ and Sands NR Combined Orthodontic—Surgical Mangement of

graft surgery and to Dr. Nigel King (Senior
Lecturer, Department of Childrens Dentistry and
Orthodontics, University of Hong Kong) for co-
ordinating parts of the treatment and for performing
the dental restorative and preventive care.
The illustrations were prepared by the Dental
Illustration Unit, Faculty of Dentistry, University of
Hong Kong. Thanks also to Connie Che for the
preparation of the manuscripts.H
Residual Palato-Alveolar Cleft Defects. Am. J. Orthod. 1976, 70: 20-37.
Turvey TA, Vig K, Moriarty J and Hoke J. Delayed Bone Grafting in the Cleft
Maxilla and Palate: A Retrospective Multidisciplinary Analysis. Am. J. Orthod.
1984, 86: 244-256.
Bergland O, Semb G and Abyholm FE. Elimination of the Residual Alveolar
Cleft by Secondary Bone Grafting and Subsequent Orthodontic Treatment.
Cleft Palate J. 1986, 23: 17S-20S.
Enemark H, Sindet-Pedersen S and Bundgaard M. Longterm Results after
Secondary Bone Grafting of Alveolar Clefts. J. Oral Maxillofac. Surg. 1987, 45:
913-918.
Robertson NRE and Jolleys A. An 11-year Follow-up of the Effects of Early
Bone Grafting in Infants Born with Complete Clefts of the Lip and Palate. Br.
J. Plast. Surg. 1983, 36: 438-443.
Boyne PJ and Sands NR. Secondary Bone Grafting of Residual Alveolar and
Palatal Defects. J. Oral Surg., 1972, 30: 87-92.

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Adulthood of 98 Cleft Lip-Palate Children. Plastic and Reconstr. Surg. 1972,
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