The orthognathic management of cleft lip and palate skeletal discrepancy: CLP series part 9

All elements of orthodontic management included in the care pathway of a patient with a repaired cleft of lip and/or palate (CLP) should be mindful of the potential for the development of facial disharmony and compromised inter-arch relationships during growth. Such skeletal discrepancies may be completely unrelated to the original congenital defect. However, previous lip or palatal surgery^1,2 has been cited as a possible cause of abnormal maxillary growth which requires orthognathic correction.

The skeletal relationship, classically associated with CLP, is a Class III discrepancy that is characterized, predominantly, by maxillary antero-posterior deficiency. Although a range of Class II discrepancies may be associated with clefts of lip or palate, this discussion will focus on the management of Class III problems. Where skeletal discrepancies are mild or moderate, the opportunity for orthodontic camouflage exists through maxillary labial segment advancement and mandibular labial segment retraction. Such approaches before adulthood should never involve mandibular tooth loss as growth prediction in CLP cases is notoriously difficult, and unfavourable late facial growth can sometimes present facial and dental relationships that can only be managed orthognathically (Figure 1). It is, therefore, important to consider the potential orthognathic needs of a patient before beginning a definitive orthodontic treatment plan. Where later orthognathic management is possible, early orthodontic interventions should ideally be limited to maxillary arch alignment alone.