Orthodontic treatment is initiated in the early mixed dentition. Fixed appliance therapy alone has been used.

The maxillary incisors, which often erupt rotated, retroclined, and in anterior crossbite, are corrected for aesthetic reasons and to ­facilitate oral hygiene. Treatment generally lasts 3–4 months.

Approximately 25 % of our patients with complete clefts of lip and palate have buccal crossbites attributable to segmental displacement.

Segmental repositioning is done just prior to the bone grafting procedure, and the orthodontic appliance is worn for 3 months postoperatively to retain the arch form. After this time, the bone seems able to retain the transverse dimension of the basal bone (any dentoalveolar relapse is corrected later). In patients with bilateral clefts, a mobile premaxilla is stabilized with a heavy rectangular arch wire for 3 months postoperatively.

When the cleft-side canine has erupted spontaneously, orthodontic treatment is resumed. The alignment of the permanent teeth follows different principles, depending on whether orthodontic or prosthodontic space closure is planned. If at all possible, we prefer orthodontic space closure because we consider bridgework in young adults to be undesirable for a number of reasons. In all patients with a missing lateral incisor in whom orthodontic space closure seems to be possible, every effort is made to move the posterior teeth forward. For these patients, we have found the Delaire-style protraction head gear to be useful. We regard this face mask as an adjunct to orthodontics and not as a means of achieving clinically significant change in skeletal relationships.

In most patients, the treatment period in the permanent dentition lasts 2 years and is completed at the age of 15. A bonded palatal retainer extending to two teeth on either side of the cleft is placed. The retainer is kept in place as long as the patient will accept it. Such retainers are unobtrusive and do not interfere with oral hygiene (Fig. 26.2).

After 25 years of bone grafting in the transitional dentition, we have analyzed 1,070 patients, of whom 232 had bilateral clefts, making the total number of grafted cleft sites 1,302.

Of these, the teeth in the cleft region were in the final position in 992 cleft sites, and thus, the interdental septum could be evaluated. Good bony interdental septum height (3/4 or more of normal septum height) was found in 96 % when the operation was performed before the eruption of the canine and in 85 % when the operation was performed after the eruption of the cleft-side canine. Failure rate: no bone formation in 1.2 %. A complete dental rehabilitation without prosthodontics was achieved in 93 % of the patients when the bone grafting was performed before the eruption of the cleft-side canine.

In order to investigate the fate of the grafted bone, we have examined 18 consecutive patients with unilateral complete CLP with 3D CT scan 20 years after bone grafting (Kolbenstvedt et al. 2002). We found good bony support of the teeth adjacent to the cleft in all cases, but there was less bone in the cleft area than on the normal side. The apertura piriformis was lower on the cleft side in all cases, and there was hypoplasia of the maxilla on the cleft side.

For autotransplantation of bone in cleft patients, several donor sites have been exploited: rib, tibia, skull, chin, and iliac crest. All of these sources have been used successfully. We have, however, found the iliac crest to be the most suitable donor site.

Serious complications are rare. Failures (i.e., no continuous bone bridge across the cleft) are probably due to poor surgical technique or infection. External cervical root resorption can occur if the root cementum is mechanically injured during the bone grafting procedure. This can be avoided by delicate surgical technique and by performing the operation at an age when the cervical region of the canine is still covered with bone (Bergland et al. 1986a).

It is important that the mucoperiosteal flaps are designed in such a way that only attached gingiva will cover the marginal part of the graft. It is our clinical observation that a completely normal periodontium seems to occur mainly in cases where the flap design has ensured an orthotopic transfer of attached gingiva to cover the marginal part of the graft.

The cleft must be widely exposed so that all scar tissue in the cleft area can be removed. The nasal floor has to be reconstructed if a fistula is present. It is important to elevate the nasal floor to achieve a good height of the alveolar crest so that the canine can be brought into a vertical position in the cleft area.

Only autologous cancellous bone creates bone that responds normally to eruption and orthodontic movement of teeth.

Timing for secondary alveolar bone grafting is critical to create an area of regenerated bone in the cleft site so that the adjacent teeth (canine and sometimes lateral incisor) can erupt spontaneously or can be moved orthodontically into it. Bone grafting before the eruption of these teeth causes their eruption through the newly grafted bone (the canine proceeds to lateral incisor position when it is missing), inducing additional bone generation and achieve higher interdental septum height. Thereafter, the presence and close approximation of these teeth prevent bone resorption. In addition, bone grafting before the eruption of these teeth allows the surrounding bone to protect the cervical region of their roots and thus prevent resorption. Maxillary growth is not disturbed when bone grafting is performed to facilitate canine eruption. Careful planning is necessary when bone grafting is performed to facilitate lateral incisor eruption because there is a possibility of causing a maxillary growth disturbance.

Secondary alveolar bone grafting using autogenous marrow and cancellous bone graft was introduced as a method for restoring tooth-bearing function (Boyne and Sands 1972, 1976). Thereafter, the central purpose for secondary alveolar bone grafting is to create an area of regenerated bone in the cleft site that is continuous with the rest of alveolus so that adjacent teeth (canine and sometimes lateral incisor) can erupt spontaneously or can be moved orthodontically into it. The timing for secondary alveolar bone grafting is critical to attain this purpose. There is a margin of time for bone grafting for other purposes, such as the stabilization of the maxillary segments, improving the soft tissue configuration to facilitate prosthetic restoration, preparing bed for the dental endosseous implant insertion, allowing closure of the oronasal fistula, and adding bony support to the alar base.

The timing of secondary alveolar bone grafting will affect the height of interdental septum at the former cleft site; tooth eruption and movement into former cleft site, which in turn affect the type of closure of the space in dental arch; root resorption; and maxillary growth. The optimal timing is going to be discussed with regard to these factors. Although various authors have presented the optimal timing based on their experience and/or investigations (Table 26.1), most practitioners so far accept that the optimal timing for secondary bone grafting is when the patient is 9–10 years old, before eruption of the canine, and the canine root is one-half to two-thirds formed. The canine eruption seems to be accelerated when canine root is two-thirds formed (Vig 1999).