Management of cleft lip and palate with a focus on orthodontic aspects

Introduction

Cleft lip and/or palate (CLP) represents the most prevalent congenital birth defect affecting facial and oral structures. This condition may be expressed clinically as complete or partial separation of the lip and/or palate. The severity of the cleft may vary, encompassing a minor notch in the upper lip to a complete lack of fusion of the lip, primary palate and secondary palate. Clefts affecting the lip, palate and facial structures may occur as isolated congenital anomalies, referred to as non-syndromic clefts , or may be associated with multiple congenital abnormalities, known as syndromic clefts . Individuals affected by non-syndromic clefts typically do not exhibit other physical or developmental anomalies, although they may present with suboptimal growth.

Studies indicate that approximately 70% of cleft lip and palate (CL+P) cases and 50% of cleft palate only (CPO) cases are non-syndromic. ^, A syndromic cleft typically involves multiple congenital anomalies (MCA) affecting different body systems. Over 350 syndromes are associated with cleft lip and palate anomaly. Some of the commonly associated syndromes include DiGeorge’s syndrome, oral-facial-digital syndrome, Robin’s sequence/complex, Treacher–Collins syndrome and Stickler’s syndrome.

A child born with a cleft lip and palate needs multiple specialists who must work in an interdisciplinary team to provide comprehensive care for the rehabilitation of the children, allowing them to live a normal life with acceptable aesthetics and functions of the stomatognathic system and normal psychosocial adjustments. Parents counselling should begin as soon as the cleft is detected during antenatal routine ultrasound review, and treatment should continue from birth to adulthood. The orthodontic aspects of cleft care are crucial and span over several years, requiring special skills to achieve optimal outcomes with minimal patient visits and burden of care.

This chapter focuses on the orthodontic aspects in the management of patients with non-syndromic cleft.

Clinical presentation

The cleft deformity can affect the lip, alveolus and both the hard and soft palate, either partially or fully, and it presents clinically in various combinations and degrees of severity. Sometimes, the cleft of the lip and alveolus may feature bands of soft tissue connecting the two sides of the alveolus, known as Simonart’s bands .

Complete clefts extend from the lip to the soft palate and can be classified as either unilateral cleft lip and palate (UCLP) or bilateral cleft lip and palate (BCLP). ^,

A complete cleft involves the lip, alveolus and both the hard and soft palate. In contrast, clefts that involve the lip and extend into any structures, from the front to the back, are classified as incomplete clefts. In the case of a bilateral cleft that affects the lip and alveolus, the philtrum of the upper lip is separated on both sides, and the premaxilla is disconnected from the remaining parts of the maxillary arch.

When a cleft extends deep into the primary palate, it creates a cleft of the alveolus in front of the incisive foramen, which is classified as a cleft of the primary palate.

Conversely, when a cleft affects the soft and/or hard palate without involving the lip and alveolus, it is categorized as CPO. These cleft types are distinct genetically and aetiologically from other forms of clefts.

Fig. 90.1 depicts a few clinical presentations of different types of cleft lip and palate.

Image, AltText currently not available — Figure 90.1

Submucous cleft palate (SMCP) is a variant of cleft palate that may not be immediately visible. It is characterised by a bifid uvula, a translucent area in the soft palate, and bony notching along the posterior edge of the hard palate at the posterior nasal spine. A submucous cleft can occur solely in the hard palate or as a soft palate defect alone. This type of cleft should be considered in cases where no other identifiable cause for hypernasal speech is apparent.

Spectrum of problems

Individuals with cleft lip and palate are affected by a range of challenges from birth, including difficulties with feeding, recurrent chest infections, hearing and speech issues, as well as frequent ear infections. The quality of life in cleft subjects is affected by poor smile aesthetics and communication difficulties related to poor articulation and unintelligible speech, leading to low self-esteem and challenges in social interactions. ^,

Operated children with cleft have midface deficiency, a class III tendency, constricted maxillary arch and residual oronasal fistulae. The facial maxillary growth of cleft patients is affected in all three dimensions: sagittal, vertical and transverse. The facial growth pattern is more vertical, with an obtuse gonial angle, short ramal height and increased anterior lower facial height. The cleft lip and alveolus growth patients may show facial growth close to normal; however, UCLP and BCLP are most affected. The constriction of the maxilla in UCLP is that of the major alveolar segment riding over the cleft side, a minor segment leading to unilateral cross bite, while in BCLP, severe bilateral constriction is noted in premolar regions.

The deviated nasal septum, enlarged turbinates and poor upper respiratory anatomy lead to altered breathing modes, snoring and obstructive sleep apnoea in these subjects, further affecting facial growth.

Dental abnormalities are frequent and include anomalies in the size, shape and number of permanent teeth, affecting anterior dentition. The maxillary incisors are hypoplastic and poorly formed; the cleft side lateral incisor is often missing, or rudimentary and supernumerary teeth may erupt in the palate. ^, The patients with cleft lip and palate may be associated with hypodontia/hyperdontia due to programmed cell death that occurs in presumed fusion epithelium and can split/kill the dental forming elements of oral ectoderm.

Frequency and severity of dental caries is high among children with cleft lip and/palate. In addition to lack of care, it may be attributed to limited access to caries protective measures and low buffering capacity in resting saliva. There are also elevated levels of salivary Streptococci and Lactobacilli in stimulated saliva.

Epidemiology of patients with cleft lip and palate

The global prevalence of cleft lip and palate is around 0.45 per 1000 live births. However, this varies among different populations due to genetic, environmental and socioeconomic factors. The incidence of this condition is reported to be highest among Afghans at 4.9 and lowest in the Negroid population at 0.4/1000 live births. In India, the prevalence of cleft lip and/or palate is estimated at 0.9/1000 in the northern region, 1.1/1000 in the southern, 0.7/1000 in the eastern and 1.8/1000 in the western region. In a study conducted in Chandigarh region Northen India, CLP incidence was found to be 0.97/1000 live births. The incidence of cleft lip and palate in AIIMS New Delhi Hospital births has been calculated as 1.4 per 1000 live births and 0.3 per 1000 live births for isolated cleft palate.

Development of cleft lip and alveolus and cleft palate

A cleft in the upper lip occurs when the maxillary and median nasal processes (MNP) fail to fuse during the early stages of facial development. This failure to merge the two processes during embryonic development leads to a separation in the upper lip, usually at the junction of the central and lateral parts on either side.

When the fusion of the palatal shelves is impaired, along with the failure of fusion of medial nasal and maxillary processes, the cleft of the lip extends further down to the secondary palate, forming the cleft lip and palate anomaly.

A cleft of the palate alone is formed due to the partial or total lack of fusion of palatal shelves, which may happen in several ways:

*
Defective growth of the palatal shelves and approximation.
*
Delayed or total failure of the shelves to elevate and attain a horizontal position with tongue’s failure to descend.
*
Post-fusion rupture of the palatal shelves.
*
Failure of mesenchyme consolidation.

Many cellular and molecular events, each playing a critical role, are involved in the fusion of the two palatine shelves in the midline. These events, such as the trans-differentiation of the epithelial cells into the mesenchymal cells (EMT) and programmed cell death (PCD) of the epithelial cells around the palatal shelves, are crucial for the fusion of palatal shelves. Any disturbance in these events and timings could lead to the failure of the union of the shelves and, hence, the formation of the cleft palate.

How to classify and group cleft lip and palate

Due to the various nature of the expression of the cleft defect and its severity, none of the classifications can include all forms and is complete for all types of uses, that is clinical and research. Several authors, researchers and clinicians have attempted to test and retest various classification systems ( Table 90.1 ). Cleft abbreviations were used in the IndiCleft Indian Council of Medical Research multi-centre project. The abbreviated grouping of clefts is practical, simple and less time-consuming. The classification devised by Lewis et al. is abbreviated and more comprehensive ( Table 90.2 ). The author recommends using this classification in day-to-day practice. For a detailed reading of other classifications, refer to the book by the author.

TABLE 90.1

Classification of cleft lip and palate

Embryological/anatomical classification	Davis and Richie were the first to present the cleft lip and palate classification based on the alveolar process in 1922. This was followed by a complicated (16 morphological forms) anatomical classification by Brophy in 1923. Veau later simplified this in 1931, which consisted of four morphological forms. Poul Fog-Anderson gave a classification based on embryological perspective in 1942 using incisive foramen. In 1958, Kernahan and Stark proposed a classification based on developmental anatomy and embryology.
ACPA	American Association for Cleft Palate Rehabilitation, later renamed to American Cleft Palate Craniofacial Association (ACPA) proposed a classification that was embryologically sound and clinically relevant for surgeons in 1960.
Symbolic	Kernahan, in 1971, proposed a symbolic representation of cleft deformity in graphic form with nasopalatine foramen as a central point. This was later modified by Elsahy, Millard and Friedman et al. to represent the cleft deformity precisely as it exists and is versatile.
Abbreviated documentation system	LAHSHAL, an abbreviated documentation system, was proposed by Kriens (1989) to allow for brief and precise recordings of non-syndromic orofacial cleft patients. Later, in 2005, the Royal College of Surgeons (UK) suggested modification by excluding the second ‘H’.
Indian classification	The Indian classification of cleft lip and palate proposed by Prof. C. Balakrishnan in 1975 is India’s most accepted classification system. He described 12 possible types of cleft deformities with 16 possible intergroup combinations in a series of over 1000 patients.
	Agarwal later modified the Nagpur classification with new notations to describe the severity and additional anatomical features.
Abbreviation system	The abbreviated grouping of clefts used in the ICMR IndiCleft project is practical, simple and less time-consuming.
	The classification devised by Lewis et al. is abbreviated and more comprehensive ( Fig. 90.1 ). For a detailed reading of other classifications, refer to the book by the author, ‘Cleft Orthodontics’.

TABLE 90.2

A simplified approach to grouping cleft anomaly and abbreviations

Based on the concept of Lewis CW, Jacob LS, Lehmann CU, Section on Oral Health. The primary care pediatrician and the care of children with cleft lip and/or cleft palate. Pediatrics . 2017;139(5):e20170628. https://doi.org/10.1542/peds . 2017-0628

Cleft classification	Abbreviation	Exclusion
Cleft lip	CL	(1) Cleft lip and alveolus; (2) cleft lip and palate; and (3) cleft palate alone
Cleft lip with or without cleft alveolus	CL ± A	(1) Cleft lip and palate and (2) cleft palate alone
Cleft palate alone	CP	(1) Cleft lip and (2) cleft lip and palate
Cleft lip and palate	CLP	(1) Cleft lip and (2) cleft palate alone
Cleft lip with or without cleft palate	CL ± P	Cleft palate alone
Cleft palate with or without cleft lip	CP ± CL	Cleft lip and cleft lip and alveolus
Cleft lip and/or cleft palate	CL/P	No exclusion

Inter-disciplinary team care

Dr. Herbert K. Cooper, an orthodontist in Lancaster, Pennsylvania, pioneered the first interdisciplinary team for treating CLP patients in 1938. His team included an orthodontist, prosthodontist, surgeon and speech therapist, forming the foundation for cleft care worldwide. Comprehensive care for CLP patients requires specialists such as psychologists, geneticists and social workers. The focus of care shifts through different life stages, with feeding specialists, surgeons and orthodontists taking lead roles early on, while speech therapy, hearing and later surgical corrections become priorities in adolescence and adulthood ( Table 90.3 and Fig. 90.2 ). An interdisciplinary coordinated team approach with defined treatment protocols has shown better treatment outcomes and reduced the overall burden of care for the child and parents. A cleft child should receive treatment with the concerned specialist at the correct age, which is critical for the successful treatment outcome ( Fig. 90.3 ). Over the years with clinical and research experience, cleft teams around the world created, modified and evolved protocols on treatment approaches, timings of surgery, speech and orthodontic care. There are subtle or obvious differences in approaches, and these are compiled in Table 90.4 . The main protocols are:

1.
The Oslo (Norway) Protocol
2.
The Copenhagen (Denmark) Team Protocol
3.
The Iowa Protocol (USA)
4.
The Toronto Protocol
5.
The Lancaster Protocol
6.
Australian Craniofacial Unit Protocol
7.
Hong Kong Cleft Management Protocol
8.
United Kingdom Cleft Protocol

TABLE 90.3

Primary team or core team

Role of multidisciplinary team members

Paediatrician
- Primary paediatric care, chest infections nutation and growth monitoring
Cleft specialist nurse
- Feeding guidance
- Preparation of patients for inpatient or outpatient care
- Communicating with other specialities and coordinating appropriate care
Plastic surgeon
- Surgical repair of cleft lip and palate
- Scar revision
- Pharyngoplasty
- Rhinoplasty
Speech therapist
- Speech evaluation and therapy
ENT surgeon
- Assessment of hearing
- Grommets
Audiologist
- Hearing assessment
Social worker
- Coordinating care with a multidisciplinary team
- Organising screening camps and support
- Cleft lip palate parents’ organisation
- Support cleft families in multiple dimensions
Orthodontists
- Correction of malalignment
- Growth modification treatment
- Comprehensive orthodontic treatment, including pre- and post-bone graft orthodontics
- Surgical orthodontics with oral and maxillofacial surgeon
Paediatric dentist
- Overall dental care
- Preventive care—regular fluoride application, oral prophylaxis and diet counselling
- Restorative dental care
- Extraction of unrestorable teeth
- Fabrication of feeding plate
Oral and maxillofacial surgeon
- Surgical repair of the cleft lip and palate
- Primary or secondary alveolar bone grafting in the cleft area
- Orthognathic surgery
- Closure of oroantral fistula
Prosthodontist
- Fabrication of obturator
- Fabrication of dentures for replacing teeth
- Palatal lift appliance
Evaluation and treatment of ear, nose and throat abnormalities
- Rhinoplasty
Clinical geneticist
- Risk assessment of future offspring
- Genetic counselling
- Identification of syndromes associated with it

TABLE 90.4

Highlights of protocols for the management of patients with cleft lip and palate

	Oslo	Copenhagen	Iowa	Toronto	Lancaster	Hong Kong	UK	Taiwan
Start of treatment	3 months	First day	1 month	1 week	At birth	At birth	Within 24 h	At birth
Pre-surgical orthopaedics	X	X	Few cases	In most BCLP	X	X	X	X
Lip surgery	3 months Millard technique (UCLP) Straight line technique (BCLP)	2-month Tennison technique, vomeroplasty	3-months modified Millard technique	3-month triangular flap, Millard technique	Rule of 10 by triangular flap	3 months Delaire’s functional primary lip repair	3 months	3–6 months
Palate repair	18 months, Von Langenbeck technique	22 months, Wardill-Kilner v or y or four flap	Second year (lip and palate) modified v–y procedure	18 months Von Langenbeck technique	At 6–12 months by one or two stage vomer flaps	18 months Two flap palatoplasty	6–12 months	Before 3 years
Primary alveolar defect closure	3 months	X	X	3 months	X	X	X	X
ENT monitoring	Begins at 3 months	From 22 months	3–4 months	2.5 years	From birth	From 1 year Once per year	X	X
Speech therapy	2–3 years	4–5 years	As early	As required	3 years	2 years	3 years	As early as possible
Secondary alveolar bone grafting	9–11 years	9–11 years	When needed	8–10 years	11 years	9–11 years	–	9–11 years

Pre-surgical orthopaedics and its evolution

McNeil was the first to introduce pre-surgical orthopaedics in 1950 for newborns with a cleft. He proposed that neonatal maxillary orthopaedics could promote the development of the maxillae and hard palate. McNeil’s philosophy focused on minimising the displacement of alveolar segments in the cleft region to create a butt joint, aiming to form a normal arch through a series of oral plates. Proponents believed this would aid palate function, normalise tongue position, support speech development, improve facial symmetry and offer psychological benefits through continuous supervision. Some even suggested it could reduce middle ear diseases and improve weight gain. However, long-term studies found these plates to be largely ineffective, and many European centres have since abandoned the practice, with better outcomes observed in places that did not use pre-surgical orthopaedics.

In the late 1950s, primary bone grafting, aimed at stabilising pre-surgical orthopaedics, gained popularity in Europe. The Kernahan and Rosenstein procedure involved using a passive appliance to mould the alveolar segments before lip surgery, followed by a rib bone graft. However, by the 1970s, it was concluded that primary bone grafting impeded midfacial growth, leading to its discontinuation. ^,

Latham appliance

Introduced in 1976 by Georgiade and Latham, the Latham appliance was an active device designed to retract the premaxilla and simultaneously expand the buccal alveolar segments. This appliance quickly moved the maxillary segments into close alignment, often paired with lip adhesion and gingivoperiosteoplasty (GPP) to stabilise the maxillary segments and reconstruct the nasal floor. While it offered rapid results, its main drawback was the need for surgical placement under general anaesthesia. Additionally, studies revealed a higher frequency of cross bites in patients treated with the Latham device, though some debate whether the GPP procedure rather than the appliance itself was responsible ( Fig. 90.4 ).

Hotz plate

Hotz introduced a passive appliance to gradually align the cleft segments by selective grinding of the acrylic material. Unlike McNeil’s approach, Hotz aimed to utilise natural growth potential rather than manipulate it for surgical facilitation. After lip surgery at 6 months, palate repair was delayed until age 5 to allow for natural growth.

Pre-surgical nasoalveolar moulding

Grayson et al. revolutionised pre-surgical orthopaedics in 1993 with the development of pre-surgical nasoalveolar moulding (PNAM), which focused on simultaneously correcting the alveolus, lip and nose. Building on Matsuo’s discovery that neonatal alar cartilage was as elastic as auricular cartilage due to the presence of high levels of hyaluronic acid at birth, Grayson added a nasal stent to an intraoral moulding plate. This stent applied gentle pressure to reshape the nasal cartilage.

The PNAM appliance consists of a maxillary plate with an attached acrylic bulb that lifts the nasal dome and moulds the nostril ( Fig. 90.5 ). Treatment typically begins within the first week of life and continues for 3 months, with regular adjustments. The procedure also involves active and passive moulding of the alveolar segments. In bilateral cleft cases, the appliance is equipped with two nasal stents and retention arms to lift the nasal area simultaneously and retract the premaxilla. Non-surgical columella lengthening is achieved using a vertical tape pull to counterbalance the upward force applied to the nasal stent.

Benefits of PNAM and controversies

The use of PNAM has been documented to improve nasal symmetry and aesthetics, especially in patients with unilateral cleft lip and palate ( Fig. 90.6 ). Studies show that the technique enhances the aesthetic outcomes of surgery by improving nasal structure, increasing columella length and retracting the premaxilla. However, despite its short-term benefits, the long-term advantages of PNAM remain uncertain, with some meta-analyses and literature reviews suggesting a minimal impact on treatment outcomes in cleft lip and palate patients beyond aesthetic improvements.

There is ongoing debate about the effectiveness of pre-surgical orthopaedics. Santiago and Grayson’s study of patients treated with PNAM and GPP showed that 60% did not require secondary alveolar bone grafts, resulting in significant cost savings. However, the long-term benefits of PNAM are still elusive, with some studies finding little evidence of positive effects beyond improved nasal outcomes. Meta-analyses and systematic reviews have found no long-term improvements in cleft lip and palate patients treated with pre-surgical orthopaedics. Moreover, logistical challenges, including the cost and frequent hospital visits, make this approach less accessible in public healthcare settings. ^,

Pre-surgical orthopaedics for protruding premaxilla

In cases of bilateral cleft lip and palate (BCLP), newborns often present with a protruding premaxilla, which may also be off-centre. Traditionally, various techniques, including adhesive lip straps, have been used to push the premaxilla back to facilitate lip closure. However, studies suggest that excessive manipulation of the premaxilla may inhibit its growth, raising concerns about the long-term impact of these interventions on primary surgery. A modified silicone bonnet cup appliance has been found effective in centralising the premaxilla, thus facilitating lip surgery. PNAM has been found effective in centralising the premaxilla and improves nasal deformity in BCLP cleft patients ( Fig. 90.7 ).

Primary surgery

Cleft lip surgery varies in timing and technique, but there is a consensus that primary lip closure should occur at around 3 months, with palate closure between 12 and 18 months. The goals of primary surgery include achieving good aesthetics and function of the lip, prolabium and columella, ensuring a proper lip seal for speech and muscle balance. Palate surgery aims to create a functioning uvula for a velopharyngeal seal during speech and swallowing while preventing fistulas. Techniques for lip closure include Tennison’s triangular flap and Millard’s rotation flap ( Fig. 90.8 ). Cleft palate repair surgeries, known as palatoplasty, utilize various techniques to reconstruct the palatal muscles and achieve a multilayered closure.

Secondary lip surgery

Secondary surgeries address remaining soft tissue residual defects. Columella lengthening and sulcoplasty are often done at 5–6 years, with rhinoplasty performed in adolescence if needed. If velopharyngeal incompetence persists, a pharyngeal flap surgery may be performed before school age.

ENT consultation

ENT (ear, nose and throat) consultations are crucial for CLP patients due to the frequent involvement of the middle ear, Eustachian tube dysfunction and related hearing issues. Cleft patients are prone to otitis media with effusion (OME) or fluid accumulation in the middle ear, which can cause conductive hearing loss. This is often due to improper middle ear ventilation resulting from abnormal Eustachian tube function, which is commonly associated with cleft palate. Previous studies have shown improvement in hearing loss after RME (rapid maxillary expansion), but a recent study showed no improvement or deterioration in hearing post-RME. ^,

Speech therapy

Children with cleft palate often experience speech and language disorders, making speech outcomes a key focus of cleft surgeries. Early evaluation by a speech and language pathologist is crucial, with initial assessments recommended by 9 months. The first 2 years are vital for speech development, aligning with primary cleft repair surgeries. ^,

Speech delays may result from middle ear fluid accumulation or hearing loss due to ossicular malformations or poor Eustachian tube function. ENT evaluations and audiometry are essential for cleft patients. Speech development relies on the structural integrity and neurosensory-motor coordination of speech-related structures, particularly the palate. Delayed palate repair, typically done between 12 and 18 months, can lead to speech issues like hypernasality, misarticulation and poor intelligibility. Scarring and oronasal fistulas may contribute to velopharyngeal insufficiency and nasal airflow issues.

Besides resonators and intact hard palate and speech articulation units, a well-functioning soft palate leading to a velopharyngeal seal, lip mobility and lip seal contribute to normal speech ( Fig. 90.9 ).

Speech assessments include evaluating articulation, resonance and nasal emission. Acrylic obturators, such as speech bulbs, help address nasality and air escape. Secondary surgeries like bone grafting, pharyngoplasty and palate lengthening are sometimes needed to enhance the velopharyngeal seal. Speech therapists and audiologists are essential members of the cleft care team, and most children require ongoing speech therapy post-surgery.

Orthodontic treatment during deciduous and early mixed dentition

The dental management of children with cleft lip and palate during the deciduous dentition phase emphasizes the preservation of the structural integrity of the teeth (caries free), which is critical for effective mastication and proper alveolar jaw growth. Although maxillary constriction may develop, it is advisable to address any crossbites present at this stage, only if they are associated with a functional lateral shift of the mandible.

In the context of early mixed dentition, orthodontic intervention is imperative for children with cleft lip and palate due to the prevalent dental anomalies accompanying this condition, including the absence of teeth, microdontia or the presence of supernumerary teeth. The erupting maxillary incisors frequently exhibit malpositioning, rotation or crossbite, all of which can adversely affect maxillary development. The objective of correcting retroclined or crossbite teeth during this stage is to facilitate optimal maxillary growth. However, caution must be exercised when managing rotated teeth adjacent to cleft areas, given the potential risks involved in compromising bone support and tooth vitality.

Patients experiencing anteroposterior maxillary discrepancies are typically treated with maxillary expansion and protraction headgear to enhance maxillary advancement. The efficacy of this treatment is heavily contingent on patient compliance, which may pose challenges in younger demographics.

Throughout the early mixed dentition phase, the orthodontic objectives centre on fostering an environment conducive to normal tooth eruption and growth, thereby preparing for future interventions such as alveolar bone grafting (ABG).

Alveolar bone grafting ^,

ABG provides a bony bridge in the alveolar cleft region, stabilizing the maxilla and supporting normal tooth eruption. ABG can be performed at various stages of a child’s development ( Table 90.5 ). SABG introduced by Boyne and Sands in 1972, revolutionised CLP treatment by allowing for the closure of alveolar defects using cancellous bone harvested from the iliac crest. This bone eventually integrates with the surrounding tissue, supporting spontaneous tooth eruption and enabling orthodontic closure of the cleft space. Before SABG, prosthodontic rehabilitation was the only option for replacing missing teeth in the cleft area.

TABLE 90.5

Alveolar bone graft nomenclature according to age

Primary ABG	It is done between birth and 2.5 years, though less common today due to growth disturbances and surgical risks.
Early secondary ABG	Performed between 2 and 5 years of age.
Secondary ABG	It is carried out between 6 and 13 years, with optimal timing being after the eruption of permanent incisors but before the eruption of canines. This timing minimises interference with maxillary growth and enhances the eruption of the canine through the grafted area.
Late ABG Tertiary ABG	Done after age 13, and in some cases, combined with Le Fort I osteotomy as a tertiary alveolar bone graft (TABG).

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