Chapter 18: Orthodontics and Possible Further Surgery

Some children with repaired clefts develop crossbites of their dentition, which means the upper teeth bite inside the lower teeth. We believe that the combination of the cleft defect in the upper jaw bone which supports the teeth, with some contraction following the surgical repair, can lead to such a crossbite. Usually it is readily corrected by orthodontic appliances, but it is often difficult to maintain such correction (which is why an orthodontic retainer is used). A bone graft in the cleft can help to permanently secure correction of the crossbite.

Children who have had full clefts of the gum pad and who have developed a dental crossbite will usually benefit from six to nine months of orthodontic arch expansion between 9 and 11 years of age. If this correction of crossbite is immediately followed by the bone graft to the cleft, there will be an important additional benefit: there will now be sufficient bone to allow the permanent canine teeth to erupt and, if necessary, to allow the orthodontist to move all the natural teeth into an even line so that there are no gaps and no malposition of teeth. Thus, a prosthesis, or denture, is less likely to be required, and your child will have a much healthier mouth by the time he or she reaches adulthood. The bone graft will also give boney support to the collapsed nose.

The second spell of orthodontic treatment follows the eruption of all permanent teeth, with or without bone grafting, and takes place somewhere between 12 and 14 years of age. Treatment may take eighteen to twenty-four months.

A small number of children with clefts (and even without clefts) grow up with severe dental crossbite and jaw deformities, with the growth of the face. These deformities can only be adequately corrected with a combined procedure of orthodontics and jaw surgery. Such treatment, which requires lengthy, careful planning, is deferred until the late teens when jaw growth is complete.

This jaw surgery (called osteotomy) will, in the majority of cases, involve both the upper and lower jaws. The maxilla, which has failed to grow forward and expand adequately, will be cut above the teeth and re-positioned according to a pre-surgically corrected plan. Usually the upper jaw (maxilla) is moved forward and the lower jaw (mandible) is pushed backward. The re-positioned jaws are then plated and allowed to heal normally, in the same way as for a facial fracture. A bone graft from the hip may also be required to fix the upper jaw in its new position.

A short period of post-surgical orthodontics will be needed in all cases and then the braces are removed and the patient has to wear retainer plates for a period of time. The length of the retainer wear will depend on the stability of the occlusion (the way the teeth meet together).

18.1 Before osteotomy


18.2 After osteotomy

Further Information

To obtain further information on "Cleft Lip and Palate: A Parent's Guide", please contact Belinda Liston:

Belina Liston
Cleft Palate Clinic Coordinator
The Cleft Palate Clinic
The Children's Hospital at Westmead
Locked Bag 4001
WESTMEAD NSW 2145
AUSTRALIA
T: + 61 2 9845 2079
F: + 61 2 9845 2078
E: BelindaS4@chw.edu.au