ORTHODONTIC-Gurkeerat Singh-Textbook of Orthodontics (2007)

Correction of Midline Diastema 645

Fig. 53.15: Treatment of midline diastema using 'M' spring Fig. 53.176: Fixed orthodontic appliance used to close the
midline diastema. Frenectomy was performed after closure of
the diastema

Fig. 53.16: Elastic thread used to close a midline diastema

• Elastic thread stretched in a figure of eight fashion
is used frequently with fixed appliances (Fig. 53.16).

• Elastic chains (Figs 53.17A to C) are also stretched
to exert forces, which are capable of closing midline
diastemas.

• Closed coil springs can be used for the same
purpose (Fig. 53.18).
Space has to be maintained for any enhancement

of the tooth material, e.g. in cases with missing laterals
or peg-shaped laterals.

Fig. 53.17A: Midline diastema present due to an ROLE OF COSMETIC
abnormal frenal attachment RESTORATIONS/PROSTHESIS

Composite build ups are recommended only in cases
where there is a tooth material deficiency (Fig. 53.19).

Textbook of Orthodontics
recommended. Composite buildups might be used as
a form of retention appliance (Figs 53.21A and B). The
build up of the central incisors is joined in the midline
to prevent the opening up of the diastema.

Fig. 53.18: Treatment of midline diastema using
closed coil spring

Fig. 53.20A: Co-axial wire bonded lingually as a
fixed lingual retainer

Fig. 53.206: Mesh bonded palatally to prevent
the midline diastema from reopening

Fig. 53.19: Composite build-up of the central
incisors for the closure of the midline diastema

Crowns can be used to make peg-shaped laterals look
more natural and esthetic. Implants may be
recommended for the replacement of missing teeth.

RETENTION

Retention is usually long-term and hence, fixed Fig. 53.20C: Fixed bonded retainer
retainers (Figs 53.20A to D) are generally

Correction of Midline Diastema 647

Fig. 53.200: Fixed bonded co-axial wire retainer

Fig. 53.21 A: Pre-treatment mid-line diastema Fig. 53.21 B: Post-treatment composite buildup

FURTHER READING 4. Motohashi K, et al. Maxillary protrusion cases treated by

1. Cetlin NM, A Ten Hoeve, Non-extraction treatment. J Clin the Bcgg technique, Odontology 1966;52:232-59.
Orthod 1983;17:396-413.
5. Motohashi K, Hioki M, Sato M. Five cases of crowded teeth
2. Edwards JC. The diastema, the frenum, the frenectomy:
A clinical study. Am J Ortho 1977;71:489-08. treated by Begg's technique, J lap Orhtod Soc 1966;25:89-
105.
3. Hammond Bi\. Treatment of a Class I crowded malocclu- 9. Motohashi K. five cases of maxillary protrusion treated
ston. Am J Orthod Dentofaciat Orthop 2002;411-8. by Begg's technique, J [ap Orthod Soc 1965;24:72-94.
7. Rockc RA. Management of a severe Class I Division I
malocclusion, Begg J Orthod Theory and Treat 1963;2:37-

47.

• Introduction Management of
• Classification of open bite Open Bite
• Etiology of anterior open bite
• Anterior open bite Gurkeerat Slngh

• Correction of anterior open bite
• Posterior open bite
• Correction of posterior open bite

INTRODUCTION ETIOLOGY OF ANTERIOR OPEN BITE

An open bite is said to exist when there is a lack of Etiologic factors that are responsible for the appear-
vertical overlap between the maxillary and mandibular ance of open bites (Table 54.1) include inherited traits
teeth. In normal circumstances the mandibular dental such as-abnormal skeletal growth pattern (short
arch is contained within the maxillary arch. Tn other mandibular ramus or an increased gonial angle) and
words the maxillary teeth overlap the mandibular abnormally large tongue size. Habits such as digit
teeth labially and buccally. Depending upon the lack sucking, mouth breathing and tonguc thrusting are
of this overlap an open bite is said to exist. more commonly implicated in the etiology of open
bites.
Open bites can exist in the anterior as well as the
posterior region. Extent can vary from being simply With majority of these habits the patient disocclu-
dental in nature to involving the underlying skeletal des his/her jaw, in other words keeps his mouth
structures. The classification and treatment will perpetually open. This over a period of time either
depend mainly on the location, etiology and the extent causes the posterior teeth to supra-erupt and/or
of the open bite. flaring and infra-occlusion of the anterior teeth.

An open bite present in the anterior segment is the Table 54.1: Etiology of anterior open bite
most unesthetic, as the patient has to bring his tongue
anteriorly between the teeth and the lips during speech Habits pattern
and while swallowing. Posterior open bites may • Anterior tongue thrust
hamper mastication and are more difficult to treat. • Digit sucking habits
• Mouth breathing
CLASSIFICATION OF OPEN BITE
Abnormally increased tongue size
i. Based on the location of the open bite, they may Inherited or ncqui.red, abnormal growth
be classified as:
• Anterior open bite ANTERIOR OPEN BITE
• Posterior open bite.
Anterior open bite is the most commonly encountered
ii. Based on the dental or skeletal components invol- severity of open bite. Even though the extent and of
ved, open bites can be classified as: its appearance may vary greatly (Figs 54.IA to E).
• Skeletal open bite, or Majority of the anterior open bites encountered in day-
• Dental open bite.

~--------------Management of Open Bite 649

Fig. 54.1 A: Anterior open bite seen unilaterally in the mixed Fig. 54.1 D: Anterior open bite accompanied by a
dentition period (the most probable cause here being the unilateral posterior cross bite
habit of placing the tongue in the space left after the loss of
a deciduous tooth)

Fig. 54.18: Anterior open bite seen in the mixed Fig. 54.1 E: Moderate anterior open bite in a young
dentition period accompanied with a mid line shift adolescent patient

Fig. 54.1e: An anterior open bite seen in an adolescent Fig. 54.1 F: Severe anterior open bite seen in a
patient. affected teeth are the maxillary and mandibular 31-year-old male patient
incisors (their flaring is quite evident)

•I Textbook of Orthodontics

Table 54.3: Appliancesused to remove the etiologyof

- '.---c.--"-~-, ~:t\!.,,:?;,.~,,<,;,;~,,:,: Wology anterior open bites
Age of the pa/ielll Appliallce used for correction

r(~.-.:.l.'2, Tongue thrust Pre-adolesccnt Fixed tongue crib/rake
.',. 10 Tongue thrust Adolescent or
. ... ".' Fixed or removable
adult tongue crib/rake
Digit sucking Pre-adolescent
Motivation and/
Digit sucking: Adolescents or medicaments
(rarely seen) Acrylic digit caps
Fixed tongue crib/rake

Fixed tongue crib/rake

Fig. 54.1G: Extremelysevere anterioropen bitecaused by Mouth Pre-adolescents ENTcheck-up followedby
an anteriortongue thrust habit(has caused not onlyflaring breathing:
of the teeth but also the loss of a mandibularincisor) • Breathing exercises

• Mouth shield

to-day clinical practice are dental in nature (Table 54.2). Mouth Adolescents ENTcheckup followedby
They are usually associated with a local cause, which breathing and adults • Breathing exercises
has to be removed for the correction of the • Orthodontic trainers
malocc1usion (Table 54.3). The persistence of
pernicious habit can lead to the malocclusion acquiring Table 54.4: Features of skeletal anterioropen bites
a skeletal component or it could be the result of a
hereditary skeletal pattern (Table 54.4 and Figs 54.2A Extraoral features:
to E). Skeletal anterior open bite can occur if there is 1. Long face due to increased lower anterior face height
incoherent growth of the maxilla and/or mandible 2. Incompetentlips
and / or anterior cranial base (Fig. 54.3). 3. An increased mandibular plane angle
4. An increased gonia! angle
CORRECTION OF ANTERIOR OPEN BITE 5. Marked antegonial notch
6. A short mandible is a possibility
The appliances used for the corrections of anterior 7. Maxillary base may be more inferiorly placed (vertical
open bites are usually used in conjunction with the
habit breaking appliances used for the elevation of the maxillary excess)
underlying etiologic cause. 8. TI1Cangle formed by the mandibular and maxillary

Unless the treatment of the underlying etiologic planes is also increased
factor is delayed and the patient is seen as an adole-
scent or an adult, anterior open bites have a tendency Intraoral features:
1. Mild crowding with upright incisors
Table 54.2: Features of dental anterioropen bites 2. Gingivalhypertrophy
3. Maxillary, occlusal and palatal planes tilt upwards
4. Mandibular occlusal plane canted downwards

lntraoral features: to regress spontaneously with the removal of the
1. Open bite limited to the anterior segment, often underlying cause (Fig. 54.4). In cases with a minor
skeletal component or where the correction is not seen
asymmetrical. spontaneously, fixed appliances should be used in
2. Proclincd maxillary and/or mandibular incisors. conjunction with a removable or fixed habit-breaking
3. Spacing between ma xili ary and/or mandibular appliance (Fig. 54.5). Box elastics of medium to heavy
forces may be used for the correction of mild to
anteriors. moderate open bites (Fig. 54.6).
4. Narrow maxillary arch is a possibility.
5. "Fish mouth" appcarrmcc.
Extraora! features:
No w1usual features.

Management of Open Bite 651

Figs 54.2A to E: Skeletal anterior open bite (A) Due to upward maxillary rotation, (8) Due to downward mandibular rotation,
(C) Due to combination of downward rotation of mandible and upward rotation of maxilla, (D) Due to vertical maxillary excess,
(E) Due to an increased flexure angle

Fig. 54.3A: Cephalogram and profile photographs of a patient with a skeletal anterior open bite
Fig. 54.38: Intraoral frontal photograph of the same patient with a skeletal anterior open bite

652 Textbook of Orthodontics

Fig. 54.4A: Spontaneous correction of a mild anterior open bite with the wearing of a
removable habit breaking appliance

Fig. 54.48: Spontaneous correction of a mild anterior open Fig. 54.5: Fixed appliances used along with a fixed tongue
bite with the wearing of a removable habit breaking appliance crib for the correction of anterior open bite

Management of Open Bite 653

Fig. 54.6: Moderates force box elastics used to close the
anterior open bit along with fixed appliances

A chin cup with a vertical pull head cap (Fig. 54.7) Fig. 54.8: Posterior open bite caused by a lateral tongue
may be used for the correction of anterior open bites thrust habit
in the pre-adolescent age group. Skeletal open bites in

adults should be treated surgically after the correction
of the existing habit. Surgery generally involves the
Le-Fort I osteotomy to impact the maxilla posteriorly.
Muscle-retraining exercises may be required following
the surgical correction.

Fig. 54.7A: Pre-adolescent patient with POSTERIOR OPEN BITE
skeletal anterior open bite
Posterior open bites are characterized by a lack of
Fig. 54.78: Patient wearing the chin cup with a contact between the posterior teeth when the teeth are
vertical pull head cap brought in occlusion (Fig. 54.8). Posterior open bites
are relatively rare and are caused mainly because of a
lateral tongue thrust habit or submerged! ankylosed
posterior teeth.

CORRECTION OF POSTERIOR OPEN BITE

The elevation of the etiology remains the main stay of
treatment. Since lateral tongue thrust is the most
frequently encountered etiologic factor, the use of
lateral tongue spikes either fixed or incorporated in a
removable appliance. form the first line of treatment
(Fig. 54.9).

Vertical elastics used along with fixed orthodontic
appliances can be used once the lateral tongue thrust
habit has been controlled. It has been noted that, most
of the posterior open bites close spontaneously
following the cessation of the tongue thrust habit.
Fixed appliances are the most frequently used means
for the correction of submerged and impacted teeth.

Fig. 54.9: Lateral tongue spicker incorporated in an FURTHER READING
acrylic appliance
1. [ohnson NCL, Sandy JR Tooth position and speech-is
there a relationship? Angle Orthod 1999;69306-10.

2. Kim YH. Anterior open bite and its treatment by means
of multiloop edgewise arch wire. Angle Orthod
1987;57:290-21.

3. Lopez-Gavito G. Wall en TR. Little RM, Joondeph DR.
Anterior open bite malocclusion: A longitudinall0-years
post-retention evaluation of orthodontically treated
patients. Am J Orthod 1985;87:175-86.

4. Mlzrahi E. A review of anterior open bite. Br J Orthod
1978;5:21-7.

5. Ngan P, Fields H. Open bite: A review of etioJogy and
management, Pediatr Dent 19:91-98,19.

6. Worms F, Meskin L, lssacson R. Open bite, Am J Orthod
1967;59:589-95.

• Introduction Management of
• Classification of cross bites Cross Bite
• Correction of anterior cross bites
Gurkeerat Slngh

• Correction of anterior cross bite in the
preadolescent age group

INTRODUCTION .'

Cross bites are a deviation of the normal bucco-Iingual 'fi~""f) .,_ ............•.•• '.•.'1.&..J..~•....
relationship of the teeth of one arch with those of the • ,I". __ .~
opposing arch. Graber defined cross bites as a condition -' .","\:' e-
where one or more teeth may be malposed abnormally,
bueeally or lingually or labially with reference 10 the Fig. 55.1 A: Singletooth anteriorcross bite
opposing loath or teeth.

Under normal circumstances the maxillary arch
overlaps the mandibular arch both labially and
buccally. But when the mandibular teeth, single tooth
or a segment of teeth, overlap the opposing maxillary
teeth labially or buccally, depending upon their
location in the arch, a cross bite is said to exist.

CLASSIFICATION OF CROSS BITES

Cross bites can be classified according to their location Fig. 55.18: Segmental anteriorcross bite
in the arch as
• Anterior cross bites (Fig. 55.1) and Posterior cross bites may be further classified
• Posterior cross bites (Fig. 55.2). according to the existence of the cross bite on one side
or both the sides of the arch as
Anterior cross bites is basically a condition where • Unilateral cross bite (Fig. 55.2C), and
a reverse overjet is seen. Anterior cross bites can be • Bilateral cross bite (Fig. 55.20).
further classified according to the number of teeth
involved as Posterior cross bites can also be classified accord-
- Single tooth cross bite (Fig. 55:1A), or ing to the extent of the cross bite as
- Segmental cross bite (Fig. 55.1B).

Posterior cross bites can also be further classified
according to the number of teeth involved as
- Single tooth cross bite (Fig. 55.2A), and
- Segmental cross bite (Fig. 55.28).

Textbook of Orthodontics

Fig. 55.2A: Single tooth posterior cross bite (maxillary right first molar)
Fig. 55.28: Segmental posterior cross bite
Fig. 55.2C: Unilateral cross bite

Management of Cross Bite

Fig. 55.2D: Bilateralposteriorcross bite Fig. 55.2E: Simpleposteriorcross bile

Fig. 55.2F: Scissors bite (maxillaryleftfirstpre-molar)

• Simple posterior cross bite: This type of cross bite is Based on the location of the etiologic factors the

seen most frequently in clinical practice. Here the cross bites can be classified as

buccal cusps of one or more posterior teeth occlude • Dental cross bite
lingual to the buccal CURpRof the mandibular teeth • Skeletal cross bite
(Fig. 55.2E). • Functional cross bite.
• Buccal non-occlusion: Here the maxillary teeth
palatal cusp of the occlusion and are placed buccal Dental cross bites are generally single tooth or
to the buccal cusp of the mandibular posterior sometimes-segmental cross bites. These usually result
teeth. The condition is also known as scissors bite from (Table 55.1) arch length discrepancy or an

(Fig. 55.2F). abnormal path of eruption. These are usually not

• Lingual non-occlusion: Here the maxiUary posterior accompanied by any threat to general health of the

tooth or teeth are placed completely palatal to the patient, the problems arising due to such cross bites

lingual aspect of the mandibular posterior teeth, are periodontal or esthetic in nature (Fig: 55.3).

Le. the buccal cusp of the maxillary tooth is palatal! Skeletal cross bite These include those cross bites, which

lingual to the lingual cusp of the mandibular are primarily due to mal-positioning or malformation

posterior teeth (Fig. 55.2G). of the jaws (Fig. 55.4). These can be inherited (c.g. Cross

Textbook of Orthodontics

Fig. 55.2G: Lingual/palatal non-occlusion (maxillary left second premolar)

Table 55.1: Etiology of dental cross bites due to trauma at the time of birth (e.g. unilateral
ankylosis of the TMJ) or later in life (Table 55.2). They
1. Anomalies of number: are capable of causing appreciable damage to a
i. Supernumerary teeth person's health and personality as the appearance may
ii. Missing teeth be compromised to a larger extent.

2. Anomalies of tooth size Functional cross bites These cross bites are usually
3. Anomalies of tooth shape caused due to the presence of occlusal interferences
4. Premature loss of deciduous and / or permanent teeth during the act of bringing the jaws into occlusion.
5. Prolonged retention of deciduous teeth These can be caused by the early loss of deciduous
6. Delayed emption of permanent teeth teeth, decayed teeth or ectopically erupting teeth. If
7. Abnormal eruptive path not corrected early, these can ultimately lead to skeletal
8. Ankylosis cross bites.

bites seen in patients with Class III skeletal pattern),
congenital (e.g. cleft lip and palate cases) or arising

Fig. 55.3: Dental cross bite leading to compromised esthetics

Management of Cross Bite 659

Fig. 55.4: Skeletal cross bite causing facial asymmetry

Table 55.2: Etiology of skeletal cross bites bites. For the selection of an appliance it is essential to
• Hereditary (Class ID skeletal structure). give consideration to these factors. At times two
• Congenital (deft lip and palate). appliances might be able to achieve the same function,
• Trauma at birth (forcep injury causing ankylosis of the at such time the cost affordability of the pa tient should
be taken into consideration as well as the ability of the
TMJ). clinician to handle the particular appliance.
• Trauma durtng growth (ankylosis of the TM) of retar-
CORRECTION OF ANTERIOR CROSS BITE
dation of growth in the traumatized bone). IN THE PREADOLESCENT AGE GROUP
• Trauma after completion of growth (malunion of
Use of Tongue Blade
fractu re segments).
• Habits (if not corrected during growth can cause). If a cross bite is seen at the time the permanent teeth
are making an appearance in the oral cavity (Fig.
CORRECTION OF ANTERIOR CROSS BITES 55.5A), a simple appliance like a tongue blade (Fig.
55.56) can correct the developing cross bite. A tongue
Depending upon the age of the patient, the eruption blade resembles a flat ice-cream stick. Tt should be
status of the teeth and the space availability various
appliances have been designed to correct anterior cross

Fig. 55.5A: Ideal case for tongue blade therapy Fig. 55.58: Tongue blade used to treat developing anterior
cross bite

660 Textbook of Orthodontics

placed inside the mouth, contacting the erupting tooth CATALANS APPLIANCE OR LOWER
in cross bite on its palatal aspect. Upon slight closure ANTERIOR INCLINED PLANE
of the jaw the opposing side of the stick comes in
contact with the labial aspect of the opposing Catlan's appliance basically consists of an inclined
mandibular tooth. This point acts as a fulcrum and if plane cemented on the mandibular incisors. The name
light forces are exerted over a couple of weeks the Catlan's appliance is generally associated with
erupting tooth can be easily made to attain a better appliances which are cemented, hence, not removable
position. Force can be generated by rotating the oral in nature. The lower inclined plane is constructed at
part of the blade labially or hold ing the blade stiffly an angle of 45° to the maxillary occlusal plane. It may
and closing the jaw slightly (till it is tolerable). be constructed for a single tooth or a group of teeth
and can be made of acrylic (Figs 55.61\ and B) or cast
The appliance is most effective till the clinical crown metal.
is not completely visible in the oral cavity and is to be
used only if sufficient space is available for the Prerequisites for the use of a mandibular anterior
correction. The only drawback is that the patient has inclined plane include:
to be cooperative for any correction to be achievable. • Enough space in the maxillary arch to align the

tooth/ teeth.

Fig. 55.6A: Acrylicinclinedplane made on the mandibularincisors

Fig. 55.6B: Side viewof Gatlan's appliance • The maxillary tooth/ teeth to be corrected should
be retroclined or erupting posterior to actual tooth
position.

• The developmental status of the mandibular
incisors should be such that they can tolerate the
forces generated.

• The mandibular incisors should be relatively well
aligned to allow appliance fabrication.

• The patient should be cooperative.
The disadvantages associated with the appliance

are:
1. The patient has difficulty with speech and chewing.

The appliance acts as an anterior bite-plane and
prevents the posterior teeth from coming into
contact.

Management of Cross Bite 661

2. The appliance cannot be given if the mandibular in cross bite and show an overbite of more than 2 mm
incisors are periodontally compromised. (Figs 55.7B and C) or the opposing teeth are
periodontally compromised. The use of a posterior bite
3. The appliance cannot be fabricated if the mandi- plane decreases or at times even eliminates the forces
bular incisors are maligned. exerted on the teeth in the opposing arch.

4. Wearing the appliance fora long duration can affect Screw Appliances
the periodontal status of the teeth on which the
appliance is retained and/or the tooth being Acrylic appliances incorporating various size screws
corrected. can be used to correct either individual tooth or
segmental cross bites. Mtcro-screue (Fig. 55.8A) are the
5. Prolonged usage of the appliance can also lead to most comfortable for the patient and can be used on
and anterior open-bite (because of posterior supra- individual teeth. Multiple micro-screws can be used
eruption). to correct individual teeth in a segmental cross bite.

6. The appliance may need to be recemented Mini-screws (Fig. 55.8B) are also used for the same
frequently. purpose but are capable of moving up to two teeth.

DOUBLE CANTILEVER SPRING/'Z' SPRING Medium screws (Fig. 55.8C) are used to correct
segmental cross bites. They are larger and are capable
The double cantilever spring or the 'Z' spring (Fig. of moving 4-6 teeth in a segment.
55.7A), as it is more frequently called, is one of the
most frequently used appliance to correct anterior 3-D (three dimensional) screws (Fig. 55.80) are
tooth/ teeth cross bites. The spring consists of a double capable of correcting posterior as well as anterior cross
helix between two parallel arms and the inferior arm bites simultaneously. Appliances incorporating a 3-D
extends as the retentive component in the acrylic base screw, achieve an overall increase in the circumference
plate. The parallel arms can be activated as per the of the maxillary arch. They are ideal to treat the
requirement to either push the entire tooth labially or anterior cross bites associated with pseudo-Class III
just the mesia I or dista I aspect of the tooth to correct a malocclusions (Fig. 55.8E).
mesio-palatal/ lingual or disto-palatal/ lingual rotation
of the tooth respectively. Face Mask or Face Mask Along with RME

The spring is effective only when there is enough In cases of anterior cross bite due to an actual skeletal
space for aligning the teeth. 1t is advisable to use the deficiency of the maxilla, at times it is possible to
spring along with a posterior bite-plane when the teeth

Fig. 55.7A: Double cantilever spring or 'Z' spring

662 Textbook of Orthodontics

Fig. 55.76: Pre-treatment. during treatment and post-treatment photographs of a patient treated with
an appliance incorporating 'Z' springs

Fig. 55.7C: Mesio-palatally rotation of 21, leading to a crossbite treated using an appliance incorporating a 'Z' spring

mesialize the maxilla using a protraction facemask Frankellll Appliance

(reverse head gear). 1£ the maxilla is narrow a rapid A Frankel III appliance may be used to correct a
developing Class III skeletal jaw structure. The
maxillary expansion screw may be employed appliance stretches the soft tissue envelop around the

simultaneously (Fig. 55.9) to aid in the transverse

expansion of the maxilla.

Management of Cross Bite 663

Fig. 55.8A: Micro-screws incorporated in a Hawley's appliance. The screw will push the tooth in the direction of the arrows
Fig. 55.8B: Correction achieved using a mini-screw

Fig. 55.8e: Correction achieved using a medium screw

Textbook of Orthodontics

Fig. 55.12A: Pre- and post-treatment photographs of a case treated with fixed appliances

Fig. 55.128: Multiple cross bites corrected using a fixed orthodontic appliance

Management of Cross Bite 667

Fig. 55.13: Coffinspring Fig. 55.14: The quad helixappliance

activate the screw or at least get it activated at regular The RME Appliance
intervals.
The rapid maxillary expansion (RME) involves a hyrax
Coffin Spring screw lype of appliance which produces high forces
capable of splitting the mid-palatine suture and
This omega shaped wire appliance (Fig. 55.13) is bringing about skeletal changes within a matter of days
capable of correcting cross bites in the young (0.2-0.5 mm/ day). The RME screw can be incorporated
developing dentition. The appliance is removable and in two type of appliances-one, the banded RME, and
usually well tolerated by the patients of this age group. the second kind, the cemented RME.
The expansion produced is slow, and bilaterally
symmetrical. In the banded RME the expansion screw is soldered
to bands which are cemented on to the first premolar
When used in the mixed dentition stage and with and the first permanent molar in the maxillary arch
better retention than the usually used Adam's clasps, (Fig. 55.15A). The cemented RME has a meshwork of
the appliance is capable of producing skeletal changes. wires which are incorporated in acrylic or cast metal
splints which are cemented to the posterior segment
Quad Helix Appliance (Fig. 55.156).

The quad helix evolved from the coffin spring and The appliance produces rapid expansion over 3-4
overcomes the short comings of the former appliance. weeks.
It is a fixed appliance (Fig. 55.14), soldered to molar
bands cemented generally on the first permanent Surgically assisted expansion using the RME can
maxillary molars. Reactivation using the three pong be achieved in adults. Generally used procedure is the
pliers, without having to is done remove the appliance. buccal corticotomy or Le-Fort I osteotomy and/ or mid-
The forces generated can be increased or decreased palatal splits. The benefits of postsurgical results
depending upon the amount of activation. It is a following RME use are still debatable.
versatile appliance and can be used along with the
usual fixed appliance therapy. NiTI Expanders

The appliance can produce slow expansion in These are nickel titanium wire shapes which can be
adolescent and adult patients and skeletal effects in attached to lingual sheath that are welded to molar
the preadolcsccnts, Since it can be reactivated, the force bands cemented to the maxillary first permanent
levels can be adjusted depending upon the require- molars (Fig. 55.16). Various sizes are available and
ment. need to be selected depending upon the amount of
expansion desired and the pretreatment width of the

668 Textbook of Orthodontics

palate. Bring about slow expansion (dental changes) Fig. 55.16: A NiTi expander brings about slow expansion
in the adolescent and adult patients.

Management of Cross Bite 669

Fig. 55.17 A: Fixed appliances used for the correction of posterior cross bites

Fig. 55.176: Red cross bite elastics worn for the correction of cross bite in the molar region

Fixed Orthodontic Appliances Cross-elnstics can be used to bring about correction
of individual tooth cross bites in the posterior segment
Fixed orthodontic appliance can be used for correction (Fig. 55.17B). Fixed orthodontic appliances are ideal
of posterior cross bites (Fig. 55.17A). The arches can for the accurate placement of teeth in a dental arch as
kept slightly expanded or constricted depending upon they provide a three dimensional control over the
the movement required. tooth.

J_

670 Textbook of Orthodontics

FURTHER READING 6. KutW1 G, Harves RH..Posterior crossbites in the deciduous
and mixed dentitions, Am J Orthod 1969;55:491-504.
1. Adkins MD, Nanda RS, Currier GF. Arch perimeter
changes on rapid palatal expansion, Am J Orthod 7. Menezes AE. Begg light wire treatment of a severe Class
1990;97:10-19. n crossbite rna locclusion, Am J Orthod, '1975;68:420-5.

2. Clifford F. Crossbitc corrections in the deciduous 8. Paync RC, Mucllcr Bh, Thomas HF. Anterior crossbites
dentition: princiles and procedures. Am J Orthod in the primary dentition. J Pcdodontics, 1981;5:281-94.
1971;59:343.
9. Ranta R. Treatment of unilateral posterior crossbite:
3. Frank SW, Engel GA. Effects of maxillary Quad-Helix comparison of the quad-helix and removable plate, J dent
appliance expansion on cephalometric measurements in Child 1988;55:102-4.
growing patients, Am J Orthod 1982;81:378-89.
10. Sandikcioglu M, Hazar S, Skeletal and dental changes after
4. Harrison I, Ashby D. Orthodontic treatment for posterior maxillary expansion in the mixed dentition, Am J Orthod
crossbites. Cochrane Review. The Cochrane Library. Issue
24 John WiJey, Chichester, 2004. Dentofac Orthop 1997;111:321-7.
11. Shivapuja Prasanna Kurnar, LepczykJ, Finn L.Transverse
5. Hermanson H, Kurol J, Ronnerman A. Treatment of
unilateral posterior cross bites with quadhelix and maxillary asymmetry treated with unilateral surgically
removable plates. A retrospective study. Eur J Orthod assisted rapid maxillary palatal expansion- a case report,
1985;7:97-102. J lnd Orthod Soc 2006;39:176-88.

Orthodontics
for Adults

Gurkeerat Slngh

• Introduction o Skeletal

• Indications for orthodontic treatment in adults ,., Motivational

n Prosthodontic • Difference between adolescent and adults
o Periodontal • Biomechanical considerations when treating adults
o Temporomandibular joint dysfunction
• Types of treatment in adults
C'J Esthetics
o Adjunctive
• Contraindications for orthodontic treatment in o Comprehensive
adults o Surgical
n Medical
• Retention and relapse in adults
o Periodontal

INTRODUCTION Table 56.1: Reasons whyadults seek orthodontictreatment

At one time, orthodontic treatment was limited to the I. Did not want orthodontic treatment as children
adolescent age group. But today, with the develop- 2. Parents or they themselves did not know about ortho-
ment of newer techniques and better understanding
of the biologic basis of tooth movement, the age up to dontics as children
which orthodontic treatment is considered possible has 3. Orthodontist was not available in the vicinity
increased considerably. Today more and more adult
patients are visiting orthodontic clinics. 4. Dentist did not advise orthodontic treatment when

The reasons why more and more adults are visiting younger
orthodontic clinics are many and varied (Table 56.1). 5. Parents could not afford orthodontic treatment
But one thing that stands out is that it is the increased 6. Incomplete or relapsed orthodontic treatment as children.
awareness about dental health that motivates the
patients to visit dentists and/or orthodontists. Since 7. Gum (periodontal) problems because of the malocclusion
orthodontic treatment is easily available and accept-
able to the patients, the general dentists are also present
recommending orthodontic intervention more fre- 8. Concerned about appearance
quently than ever before. The prevalence of 9. Can afford orthodontic treatment now
periodontal problems and their established association 10. Malocclusfons like spacing/crowding becoming more
with malaligned teeth has also helped advocate the
case for orthodontics. prominent with age
11. Advised by prosthodontist,prior to fixedreplacementof
For all practical purposes, an adult is defined as a
person who has ceased to grow. Biologically, this teeth
happens at around 18 years of age. For orthodontic 12. Advised by periodontist, to prevent further deterioration
purposes, it is better to classify adult patients as:
of periodontal condition

13. TM) problemsarising due to the malocclusion
14. Overall heightened concernabout dental health

Group J 18 to 25 years of age

Group TT 26 to 35 years of age

Group Ill 36 years and older

The first group patients are generally treated as

other adolescent patients. They may exhibit heigh-

672 Textbook of Orthodontics

tened concerns for esthetics, but otherwise they are
periodontally healthy. The second group exhibits more
periodontal and restorative problems. Whereas, the
third group will invariably present prosthodontic
complications and may lack a full complement of teeth.

INDICATIONS FOR ORTHODONTIC Fig. 56.1: Parallelismof tipped abutmentteeth
TREATMENT IN ADULTS can be achieved

Why undertake orthodontic treatment in adults? Is
it only to improve the esthetic demands of the patient
or just because we have better techniques today?
Indications for orthodontic treatment can be broadly
classified into four categories:
1. Prosthodontic
2. Periodontal
3. Temporomandibular joint (TMJ)
4. Esthetic.

PROSTHODONTIC INDICATIONS FOR Fig. 56.2: Maxillaryrightfirst molarsupra-eruptedin the
mandibularrightfirstmolar extractionsite
ORTHODONTIC TREATMENT OF ADULTS

Prosthodontists are advocating fixed prosthesis in
more and more patients. Certai.n criteria need to be
fulfilled before teeth can be used as abutments, these
relate to parallelism of abutment teeth, redistribution
and redirection of occlusal and incisal forces,
improvement of crown/root ratio, etc. (Table 56.2).

Orthodontic appliances can upright teeth that have
tilted into extraction spaces. They are even more
frequently used to achieve parallelism of abutment teeth
(Fig. 56.1). They are also used to distribute teeth more
favorably both inter-and intra-arch. Teeth that have
supra-erupted and prevent the placement of prosthesis
in the opposing arch can be intruded (Fig. 56.2).
Orthodontic appliances can act as space re-gainers,
and can help achieve regain lost space into which
prosthesis may be placed (Fig. 56.3).

Table 56.2: Prosthodonticindicationsof Fig. 56.3: Mesiaitiltingof the rightmandibular3rd molar into
orthodontictreatment the extractionsite of the 2nd molar,leadingto the decrease in

• Parallelism of abutment teeth the extraction space
• Uprighting of tilted teeth
• Regairung lost extraction spaces
• Derotation of abutment teeth
• Intrusion of supra-erupted teeth
• Distribute abutment teeth mOre favorably

Orthodontics for Adults

PERIODONTAL INDICATIONS FOR
ORTHODONTIC TREATMENT IN ADULTS

Crowding of teeth: It is a proven fact that crowding of

teeth leads to accumulation of plaque, which if not

removed can cause subsequent periodontal break-

down. Crowded teeth are difficult to clean (Fig. 56.4)

as the bristles of the routinely used toothbrushes

cannot reach the embrasures so created. Once these

teeth become well aligned, oral hygiene procedures

can be carried out more easily and efficiently.

Spacing between teeth is not only unsightly but also

provides an ideal location for food lodging. This can

lead to the formation of periodontal pockets and

associated loss of bone. Spacing in the anterior seg-

ment is often associated with periodontal breakdown Fig. 56.5: Periodontalbreakdownfollowingchildbirthcausing

following pregnancy in middle-aged women (Fig. spacing and proclinationof the maxillaryanteriorteeth

56.5). An orthodontist can close these gaps and help (Fig. 56.7) which was acceptable for 30 years suddenly

to ma intain the resul ts. becomes unsightly as the malocclusion starts

TEMPOROMANDIBULAR JOINT DYSFUNCTION worsening following a generalized loss of periodontal
The term is a symptom and encompasses a varied health.

nu rnber of underlying ea uses. It can often be the result CONTRAINDICATIONS FOR ORTHODONTIC
of over-closure, caused due to an early loss of posterior TREATMENT IN ADULTS
teeth or / and decrease in the lower facial height. Ortho-
dontist can elevate symptoms and use of splints can The buzz word is-'don't over do it'. Yes, science has
be beneficial before any prosthetic rehabilitation. progressed, but the bottom line remains that do not
try it if you think it is not possible. The situation may

ESTHETICS arise beca use of four main reasons:

This remains and will remain the most important a. Medical: The patient is medically compromised to
motivation for a patient to seek orthodontic treatment. an extent that bone formation itself is likely to be
An incisor drifting anteriorly (Fig. 56.6), or a cross bite compromised. Especially in cliseases like diabetes
rnellitus, the healing capacity of the tissues is much

below normal and treatment should be avoided.

b. Periodontal condition of the patient is poor, with

multiple mobile teeth. Patients who do not main-

tain good oral hygiene are poor candidates for

orthodontic treatment irrespective of the age of the
patient.

c. Skeletal molocclusions, which require surgical

intervention, also might not be undertaken because

of the extent of medical and for physical condition
of the patient.

d. Motivation of the patient is essential. Do not start

treatment, if at the time of evaluation itself it is felt

that the patient is skeptical of the procedure being

advocated. It is advised not to proceed with the

Fig. 56.4: Crowdingassociated withpoor oral hygiene treatment unless the patient is found to be deter-
mined to see the therapy through to completion.

Textbook of Orthodontics

Fig. 56.6: Pre- and post-treatment photographs of a 34-year-old female patient treated for a protruding
central incisor. Following active treatment. a fixed retainer was bonded lingually

DIFFERENCE BETWEEN ADOLESCENTS be ignored for all practical ptuposes in adults. In a
AND ADULTS (TABLE 56.3) way, this makes it easier for the clinician as he is
expected to undertake only dental changes, which are
Both adolescent and adults, if cooperative can be usually simpler to achieve as compared to growth
treated equally well orthodontically. The two modification procedures, Periodontal disease, which
differences which can play havoc with any orthodontic is rarely seen in growing children, becomes a major
appliance therapy are growth and the degree of factor when planning orthodontic treatment for ad ults.
periodontal breakdown. Growth is a factor that can The degree of periodontal breakdown and the

-"---------------- Orthodontics for Adults 675
Table 56.3: Differences between adolescent and adult patients

Chamcteristic Adolescent patient Adult patiellt

Growth potential Growth modification may be possible. No growth possible. Correction limited to tooth
movement
TMJ adaptability Adaptable of periodontal Frequently shows signs of TMJ dysfunction
Periodontal problems Periodontal problems arc frequently encountered
Rarely show symptoms
General health disease Might be of major concern, especially if surgery
Rarely a consideration is planned
Appliance esthetics Of major concern to the p,alicnl
Retention pla.nning Rarely of concern Long-term and usually fixed

Appliance tolerance Usually short-term and with removable More time is required to get accustomed to the
appliances appliance
Speech Will usually tolerate and get used to all Adjustment takes time and effort
Motivation and orthodontic appliances soon Usually good
cooperation
Treatment appreciation Adjusts quickly Usually very appreciative

Ranges from poor to excellent

Ranges from hardly concerned to very
appreciative

Fig. 56.7: An anterior cross bite that the patient started BIOMECHANICAL CONSIDERATIONS
perceiving as unsightly after he turned 30 WHEN TREATING ADULTS

resultant bone loss around teeth might determine and Orthodontic appliances should always be chosen
at limes even dictate the course of treatment for adults. depending upon the malocclusion and in the case of
adults-the patient's expectations. Expectations can
Generally, adult patients are better motivated and be with regards to the esthetics of the appliance or the
will standby their commitments on oral hygiene and results desired. The capability of the orthodontist to
appliance maintenance. Adults definitely take longer treat cases with different appliances also plays a major
to get used to the appliance, but they appreciate results role here.
better and hence, it is a more satisfying experience
treating adult patients. The most esthetic appliance is the lingual appliance
(Fig. 56.8) but labially placed esthetic brackets (Fig.
56.9) might be more commonly used. This is because
very few orthodontists are trained in the Jingual
technique, Also, a lingual orthodontic treatment will
be much more expensive as compared to treatment
with any other appliance.

111etraditional adolescent treatment objectives are
toned down without necessarily compromising treat-
ment results to incorporate minimal dental mani-
pulation appropriate for the individual case. In other
words, move only those teeth that are essential to
achieve acceptable results. At times, space may be
created by proclining teeth (Fig. 56.10) or extracting a
single tooth (Figs 56.1lA and B) or single arch

Textbook of Orthodontics

Fig. 56.8: The lingual appliance. Fig. 56.9: Patient being treated with ceramic brackets.
(Photograph courtesy: Or Vinod Verma) A ceramic-coated wire and transparent elastomerics can
also be seen

Fig. 56.10: Space created for alignment by proclining the anterior teeth. Permanent retention is a must for the
retention of such cases

Fig. 56.11A: Pretreatment photographs of a case treated with the extraction of only the
maxillary right 1st premolar

Fig. 56.11 B: Post-treatment photographs of the case treated with the extraction of only
the maxillary right 1st premolar

extractions are more commonly done, rather than the With advancing age, certain changes take place in
the oral tissues which have a bearing on orthodontic
routine all first premolar extraction. The scope for tooth movement. Some such changes are seen in all
adult patients treated. These are as follows.
segmentaltrealrnent is increased in adult patients (Figs

56.12A to C).

Orthodontics for Adults 677

Fig. 56.12A: Pretreatment photographs of a patient treated with segmental lingual appliance

Fig. 56.128: Photographs of the patient with the segmental lingual appliance in place

Fig. 56.12C: Posttreatment photographs of the patient after completion of active treatment

678 Textbook of Orthodontics

CHANGES IN THE TOOTH STRUCTURE 2. Proximal overhangs-causing formation of

Occlusal Facets periodontal pockets;

Occlusal facets are more common in adults as 3. Deficient occlusal carving may cause loss of
com pa red to adolescent (Fig. 56.13). These might cause
resistance to movement, as the teeth tend to inter- occlusal contacts, decreasing the chewing cap-
digitate better and more perfectly.
ability of the patient.
Dental Caries
4. Teeth restored with ceramic crowns or laminates
Adults are most susceptible to recurrent dental caries,
and these might increase the chances of the tooth being may also pose problems while bonding of
root canal trea ted. Root cana 1 treated teeth might show
more root resorption as compared to normal healthy orthodontic attachments.
teeth.
CHANGES IN THE 'U'
Restorative Failures
As the age advances, the periodontisrn is weakened
As the patient's age progresses, so do the chances of and its reparative capacity is reduced.
him/her having dental restorations.
Adults exhibit higher susceptibility to periodontal
Restoration with: bone loss as compared to adolescent. Decrease in the
1. Improper contours leading to the loss of proper alveolar bone height of teeth tends to decrease
periodontal support. Forces have to be accordingly
contacts; decreased to move such compromised teeth. Also, this
causes a change in the center of resistance which shifts
more apically (Fig. 56.14). Hence, not only the
magnitude of the force has to be decreased but bracket

Fig. 56.14: Changes in the center of resistance
withalveolarbone loss

Fig. 56.13: Pronounced occlusalfacets in an adult patient placement might have to be altered. The further away
the point of application of force from the center of
resistance, the more the chances for the tooth to tip.
Tipping movement is the easiest to achieve.

The adult bone is more dense and less vascular.
Also, as age progresses, the overall rates at which cells
are produced decreases. And this in turn might lead
to decrease in the rate at which adult teeth move and
stabilize. The more slowly the bone forms the longer
and more critical the retentive phase becomes.

Orthodontics for Adults 679

MISSING TEETH Profitt has classified adult orthodontic treatment
procedures as:
Premature Loss 1. Adjunctive orthodontic treatment
2. Comprehensive orthodontic treatment
Premature loss of teeth might cause: 3. Surgical orthodontic treatment
1. If replaced in time-presence of removal or fixed
ADJUNCTIVE ORTHODONTIC TREATMENT
prosthesis in the patient's mouth or
2. If not replaced within a reasonable period of time- These are procedures which are done as precursors or
in conjunction with other dental procedures. These are
(a) supra-eruption of the tooth in the opposing arch; generally done to facilitate further prosthodonti.c or
(b) tipping of the tooth distal to the extraction site. periodontal rehabilitation of the patient. These are the
This often leads to narrowing of the bone at the most commonly undertaken procedures in the patients
site of extraction-moving a tooth into such a site who fall in the Group II and III age groups.
is usually difficult and might lead to loss of
attachment and mobility. The goals of adjunctive orthodontic treatment
include:
TEMPOROMANDIBULAR JOINT (TMJ) 1. Parallelism and/or derotation of abutment teeth

The temporomandibular joint is one thing that is often (Fig. 56.15).
not considered important while treating adolescent. 2. Elimination of crowding (Fig. 56.10)
This is mainly because they exhibit high degree of 3. Elimination of anterior spacing (Fig. 56.16), which
adaptability and rarely any symptoms of TMj
dysfunction. It is exactly the opposite with adults and might be causing frequent food lodgment or
the joint should be evaluated not only while esthetic problems.
diagnosing the case but also monitored during and 4. Establishing a more favorable distribution of teeth
after treatment. (Fig. 56.17)
a. Inter-arch
TYPES OF TREATMENT IN ADULTS b. Intra-arch, to facilitate prosthetic rehabilitation.
5. Establishing a more favorable crown-to-root ratios
Adults present with multiple problems and these need and/or intrusion of specific teeth.
not be only classified as simple rnalocclusions. All the above mentioned treatments mayor may
Orthodontic treatment needs to take into consideration not require the placement of full jaw orthodontic
the periodontal and/or prosthodontic rehabilitation appliances. Most of these procedures can be accom-
of the patient, depending upon the intensity of plished by using segmenta 1treatment (Figs 56.12 and
malocclusion and the amount of orthodontic correc-
tion required.

FIg. 56.15A: Pretreatment photographsmalalignedabutment teeth (mandibularlateralincisors)

Textbook of Orthodontics
Fig. 56.156: Segmental appliance in place to align mandibular lateral incisors

Fig. 56.15e: Posttreatment photographs with the mandibular lateral incisors in ideal position to
serve as abutments for a fixed prosthetic appliance

Fig. 56.16A: Unsightly anterior spacing pre and post-treatment photographs

56.15).ln other words, the appliance is limited to only COMPREHENSIVE ORTHODONTIC
a portion of the dental arch and does not alter the TREATMENT FOR ADULTS
occlusion per se. The treatment duration is less as
compared to a comprehensive treatment plan. Comprehensive treatment is similar to treatment
undertaken in adolescent and is most frequently

Orthodontics for Adults 681

Fig. 56.166: Midlinediastema treated using segmental lingualarch appliance in a 56-year-oldfemale
patient. Notethe fixedfiber splintin place palatalto the maxillaryincisorsfor retention

undertaken in the Group I patients. It involves full 1. Dentofacial esthetics
fledged treatment with or without extraction of teeth. 2. Stornatognathic function, and
The orthodontic appliance is usually the bonded kind 3. Stability
and esthetic brackets are frequently used (Figs 56.11
and 56.16). Comprehensive treatment patients are orthodontic
patients in the true sense. They approach or are
The treatment objectives of comprehensive referred to orthodontists for the malocclusion that is
orthodontic treatment for adults are the same as for inflicting them and not because of any preprosthetic
adults, namely: or periodontal treatment that may be required. Even

Textbook of Orthodontics

Fig. 56.17 A: Pretreatment photographs of a 65-year-old man with relroclined maxillary incisors

Fig. 56.178: Patient with appliance in place, flexible NiTi wire

Fig. 56.17e: Patient with appliance in place, stainless steel wire

though, the malocclusion may ultimately lead to such According to Profitt, comprehensive orthodontic
treatment. For example, if anterior crowding is left treatment would last for a duration of more than 6
untreated, it might cause accumulation of plaque; and months. Generally, fixed appliance therapy may last
if proper oral hygiene is not maintained-periodontal from 1 to 1"years.
breakdown.

Orthodontics for Adults 683

Fig. 56.170: Post-prosthodontic rehabilitation photographs of the patient
(Prosthetic rehabilitation Courtesy Or Abhay Lamba)

Comprehensive treatment mayor may not be achieve proper inter-digitations and final positions of

combined with surgical orthognathic treatment. teeth for balance, stability and esthetics.

SURGICAL ORTHODONTIC RETENTION AND RELAPSE IN ADULTS
Retention mechanics are planned as part of the original
TREATMENT IN ADULTS treatment plan itself. In adults, fixed retention is made
use of most frequently as relapse is more common.
Orthognathic surgery is a distinct identity in itself and
has been discussed separately. But it is pertinent to Generally, in theadultage groups bonded retainers
mention here that after the cessation of growth, the are used (Fig. 56.18). Now with the advent of better
only way to correct true skeletal malocclusion has to splinting materials, these are being extensively used
involve surgery. This branch of dentofacial surgery to splint the periodontally compromised adult teeth.
has come far in the past decade. Our knowledge of
anatomy and the advent of newer surgical aids have Fig. 56.18: A fixed bonded coaxial wire retainer in place
helped its cause.

A team approach is essential to carry out surgical
orthodontic procedures. Here, three procedures are
involved in sequence:
1. Presurgical orthodontics
2. Orthognathic surgery proper
3. Postsurgical orthodontics.

Presurgical orthodontics helps in achieving a
proper alignment and levelling of arches individually.
Orthognathic surgical procedures are used to establish
a proper skeletal relationship. This involves the
planned skeletal fracturing of individual skeletal
bones-maxilla, mandible, etc. and their repositioning
with the help of bone plates or wiring as required. Jaw
discrepancies in all three planes of space can be
corrected. Postsurgical orthodontics then helps to

684 Textbook of Orthodontics

Fig. 56.19: Composite build-up of the maxillary incisors to compensate the tooth material arch length discrepancy

Table 56.4: Considerations to be kept in mind This not only acts as a splint and causes more uniform
while treating adult patients distribution of forces but also maintains the achieved
orthodontic relationship.
Existing oral diseases
1. Dental caries Sometimes prosthetic rehabilitation will help and
function as a retention appliance. Tooth material
• Recurrent decay can cause restorative failures discrepancies can be overcome by reducing the size
• Pulpal involvement can lead to root canal treated of the teeth by proximal stripping or building teeth
mesiodistally using composite materials (Fig. 56.19).
teeth that are more prone for root resorption during
orthodontic tooth movement Overall adult orthodontic treatment is a reality and
Large restorations might prevent bonding of more and more patients are going to require it. It is
attachments for the clinician to learn the latest and provide the adult
patients with the desired results (Table 56.4).
2. Periodontal disease
• Higher susceptibility for periodontal bone loss FURTHER READING

3. fllUliy restoration 1. Craber TM. Cranio-facial morphology in deft palate and
• Problems associated with improper interproximal cleft lip deformities. Surg Cynec Obstet 1949;88:359-69.
contouring can lead to improper contacts
• Proximal overhangs may cause periodontal pockets 2. Custke Cl. Treatment of periodontitis in the diabetic
• Insufficient occlusal carving might prevent proper patient. A critical review. J Clin Periodontal 1999;26:133-
interdigitation 37.

4. TMj adaptability 3. Huddaart AC, North JF, Davis MEH. Observations on the
• Adults frequently show symptoms ofTMJ dysfunction treatment of cleft lip and palte, Dent Prac, 1966;16:265-74.

5. Occlusal nwarenl!SS is Jzei,~lltelled Witll enamel wear and adverse 4. Nattrass C, Sandy JR. Adult orthodontics-a review. Br)
c}/fwges in tue supporting tissues Orthod 1995;22:331-37.

Skeletal and neuromuscular considerations 5. Pruzansky S, Aduss H. Prevalence of arch collapse and
malocclusion in complete unilateral deft lip and palate,
6. Grounh factor Trans Europ Ortho Soc, 1967;1-18.
• No growth possible with minimal skeletal adaptability.
Surgical procedures like surgically assisted R1vfEmay 6. Rosenstein SW, New concept in early orthopedic treatment
be required of cleft lip and palate. Am J Orthod, 1969;55:765-74.
Dental camouflage for mild to moderate skeletal
dtsharrnonles 7. Shaw WC, Sernb C. Current approaches to the orthodontic

7. DC/'Ilojacial est"etics management of cleft lip and palate, J R Soc Med,
• Concern is occasionally disproportionate to the degree
of existing problem 1990;83:30-3.
8. Tessier P. Anatomical classification of facial, craniofacial
8. Neuromuscular maturity
• There is a general lack of neuromuscular adaptability, and latero-facial clefts, J Maxillofac SlIrg 1976;4:69-92.
which may lead to a tendency towards iatrogenic
transitional occlusill traUITH'I

Management of Cleft
Lip and Palate

Gurkeerat Singh

• Introduction • Embryological background
• Historical review • Possible mechanisms for formation of isolated
• Incidence
• Factors influencing incidence cleft palate

• Etiology • Classifications
• Problems associated with cleft lip and palate
• Management of cleft lip and palate

INTRODUCTION

Cleft palate can be defined as 'a furrow in the palatal Fig.57.1: Variouspresentationsofcleftlipand palate(A)Partial
vault'. It may be defined as 'breach in continuiuj Ofpalate'. unilateral involvinglip (B) Complete unilateral involvinglip
Cleft lip or hare lip (Fig. 57.1), as it is commonly called, (C) Partialbilateralinvolvinglip(D)Completebilateralinvolving
along with the cleft palate are the most commonly seen lip
congenital deformities at the time of birth. Clefts of
lip and palate can occur i.ndividually or together in the palate from the underlying bone. He also
various combinations and/or along with other recommended the use of lateral relaxation incisions
congenital deformities. The management of deft palate in the soft tissues of the hard palate to close clefts of
is not limited to anyone of the specialties but involves velum and hard palate.
a number of specialists of medical science in order to
get a composite, esthetic and functional result. This Tergusson in 1844 and Von Langenback in 1862
chapter is aimed at providing the dental student an emphasized the need to elevate periosteum with the
overview of the topic with emphasis on the role of the palatal mucosa, thus creating a mucoperiosteal flap.
dental surgeon and the orthodontist.

HISTORICAL REVIEW

Records suggest that hare lip was reported as far back
as 1000 AD . Parea, a French surgeon in 1561 was the
first who try to put an obturator to fill the cavity
produced by a cleft in order to facilitate eating and
speech. Le Monnier a French dentist in 1764 tried to
repair cleft palate surgically. Many attempts were
made Loclose the cleft palate surgically, but failed due
to the tension developed at the median suture. In 1826,
Diffenbach suggested the separation of soft tissues of

686 Textbook of Orthodontics

Surgeons were thus provided with a 'technique by BIRTH WEIGHT
which hard palate clefts could be closed more
successfully than ever before. During the first World No significant correlation was found between birth
War, Harold Gil/es and Pomfret Kilner in London, Victor weight and incidence of cleft. However, some
View in Paris and so many other surgeons developed investigators have found that babies with isolated cleft
their skill to repair the cleft. palate had lower birth weight than those with isolated
cleft lip.

INCIDENCE PARENTAL AGE

Incidence of cleft lip and palate has increased from 1 An increased incidence has been reported with
per thousand live births in first third of the century to increasing parental age by some investigators. It is
1.5 to 2 per thousand. The incidence varies widely and possible that frequency does increase somewhat with
is the least in the Negroids (Table 57.1). The advancing parental age, particularly the mother's.
Mongoloids show the highest incidence. The incidence
varies widely in the Indian subcontinent. SOCIAL STATUS

Unilateral clefts account for nearly 80 percent of No variations in frequency of cleft lip or palate have
all clefts seen, while bilateral clefts account for the been reported with social class. This suggests that
remaining 20 percent. Among the unilateral clefts, factors such as malnutrition or infectious diseases may
clefts involving the left side are more common (70% not be important in causing cleft lip or palate.
of the cases). Male patients show a higher incidence
of cleft lip or palate. Female patients show a higher BIRTH RANK
incidence of cleft palate as compared to cleft lip.
No significant correlations have been found associa-
Table 57.1: Incidence of cleft lip and or cleft palate per ting birth rank to clefts. Some investigators claim that
thousand live births incidence is more in the first born child. Also if one or
both the parents are suffering from some form of cleft
Caucasians 1 the probability rises considerably.
Japanese 1.7
Negroids 0.4 ETIOLOGY
American Indians 3.6
Afghans 4.9 HEREDITARY
Czechoslovakia (Erstwhile) 1.85
Denmark 1.1 According to Fogh and Anderson, less than 40 percent
of cases of cleft lip with or without cleft palate are
Indians 1.7 genetic in origin. And less than 20 percent of isolated
cleft palates are genetically determined.
FACTOR INFLUENCING INCIDENCE
According to Bhatia, the two possible modes of
SEX transmission are-by a single mutant gene producing
a large effect, or by a number of genes (polygenic
Cleft lip and/or palate is more common in males than inheritance) each producing a small effect together
in females. Around 70 percent of cleft lip and palate is creating this condition. More recently, researchers
found in males while cleft palate is more common in have expanded upon this concept and reiterated that
females. there are two forms of cleft. The most common is
hereditary, its nature being most probably polygenic
RACE (determined by several different genes acting
together). In other words, when the total genetic
Japanese population shows a higher incidence than liability of an individual reaches a certain minimum
Caucasians and Negroes. level, the threshold for expression is reached and cleft
occurs. Actually it is presumed that every individual

Management of Cleft Lip and Palate 687

carries some genetic liability for clefting, but if this is An alcoholic mother may give birth to a child with
less than the threshold level, there is no cleft. When foetal alcoholic syndrome which may be associated
the individual liabilities of the two parents are added with deft palate. Thalidomide may have a similar effect.
together in their offspring, a cleft occurs if the
threshold value is exceeded. Radiation

The second form of deft is monogenic or syndromic Today, radiations such as X-rays, gamma rays etc. are
and is associated with a variety of other congenital used widely in medicine for diagnosis and treatment.
anomalies. Since these are monogenic, they are the These are ionizing radiation and are capable of
high-risk type. producing either somatic or genetic effects. Somatic
effects are those which become manifested in the
Multifactorial Threshold Hypothesis exposed individual. Genetic effects are those which
are expressed in individual's descendents. The genetic
Multifactorial inheritance theory implies that many effects include anomalies such as cleft palate, cleft lip,
contributory risk genes interact with one another and microcephaly and neonatal death. These radiation
the environment and collectively determine whether anomalies are due to the irradiation of the embryo!
the threshold of abnormalities is breached, resulting fetus during pregnancy.
in a defect in the developing fetus. This theory explains
the transmission of isolated cleft lip or palate, and it is Diets
extremely useful in predicting occurrence risks of this
anomaly among family members of an affected Dietary deficiency of riboflavin, folic acid and hyper-
individual. vitaminosis A, may act as environmental teratogens.

CONGENITAL EMBRYOLOGICAL BACKGROUND

The word congenital and hereditary differs in The fusion of various embryonic processes around the
meaning. Congenital refers to an anomaly which must stomodeum (the primitive oral cavity), leads to the
be present at birth. It can either be hereditary, formation of the nasomaxillary complex.
genetically determined or induced (environmental
teratogens). Hereditary anomalies mayor may not be The mesoderm covering the forebrain proliferates
present at birth and may appear in due course of time. and descends towards the stomodeum. This process
Congenital anomalies may be brought about by the is called the fronto-nasal process. As the nasal pits
following agents!teratogens: develop, the fronto-nasal process gets divided i.ntothe
medial nasal process and two lateral nasal processes.
Infections
The first branchial arch, ealied the mandibular arch,
Infections like Rubella, Influenza, Toxoplasmosis, etc. is placed lateral to the developing stomodeum. From
to the mother during pregnancy may cause formation its dorsal aspect, it gives rise to the maxillary process.
of the deft in the fetus. The maxillary processes join the lateral and the medial
nasal processes to form the future upper lip and
Drugs maxilla.

Cases have been reported in which acute hypoxia The maxillary processes gives rise to the palatal
prod uced by carbon monoxide or morphine overdose was shelves. The palatal shelves grow medially and as the
followed by a birth of a malformed child. Aminopterin, developing tongue descends downward, the palatal
an antifolic drug is occasionally used as an shelves fuse with the fronto-nasal process to form the
abortifacient. Surviving fetuses of such abortion palate. Failure of fusion results in clefts of the palate.
attempts were grossly malformed. All cytotoxic
anticancer drugs such as alkt)lating agents have been The mandibular process gives rise to the lower lip
blamed for producing clefts. Cortisone is a suspected and jaw. Defective fusion or incomplete fusion
teratogen. between the various processes leads to different types
of cleft formations.

688 Textbook of Orthodontics

POSSIBLE MECHANISM FOR FORMATION Group I
OF ISOLATED CLEFT PALATE Clefts restricted to the soft pala te.

1. Agenesis or hypoplasia of the tissues involved. Group 11
2. Palatal tissues may be obstructed from moving Clefts involving the hard and the soft palate, but
limited up to the incisive foramen.
dorsal to the tongue by lack of intrinsic or extrinsic
motivational force or by physical obstruction. Group III
3. Poor adherence of the medial edge epithelium of Complete unilateral clefts of the soft and hard palate.
the palatal process to each other or a delay in
transposition, until fusion capacity is lost. Group IV
4. Persistence of midline seam due to a failure of Complete bilateral clefts of the soft and hard palate,
cellular degeneration might result in post-fusion the lip and the alveolar ridge.
breakdown in the midline.
5. Lack of mesenchymal growth in the midline region
may result in submucous cleft formation.

CLASSIFICATIONS CLASSIFICATION BY FOGH ANDERSON (1942)

DAVIS AND RITCHIE'S CLASSIFICATION (1922) Group I
This was one of the first recognized classifications. The
classification was based on the location of the cleft Included clefts of the lip; and is subdivided into:
relative to the alveolar process. The classification • Single-Unilateral or median clefts
divided all clefts into three groups as: • Double-Bilateral clefts.

Group I Group 11
Preal veolar clefts or in other words clefts restricted to
the lip region only. The group was subdivided Included cleft restricted to the lip and the palate. They
depending on the location of the cleft as: are subdivided as:
• Unilateral • Single-Unilateral clefts
• Median • Double-Bilateral clefts.
• Bilateral
Group III
Group 11
They are clefts of the palate extending up to the incisive
Postalveolar clefts, i.e. clefts involving the soft palate foramen.
only, or clefts involving the soft and hard palates, or a
submucous cleft. SCHUCHARDT AND PFEIFER'S
SYMBOLIC CLASSIFICATION
Group III
Alveolar clefts, i.e. complete clefts of the palate, This was the first diagrammatic classification. It makes
alveolar ridge, with subdivisions based on the location use of a chart made up of a vertical block of three pairs
as: of rectangles with an inverted triangle at the bottom
• Unila teral (Fig. 57.2). The inverted triangle represents the soft
• Median palate, while the rectangles represent the lip, alveolus
• Bilateral and the hard palate as we go down. Areas affected by
clefts are shaded on the chart. Partial clefts and total
VEAU'S CLASSIFICATION (1931) clefts were shaded in different colors.

Veau classified clefts into four broad groups. It is a relatively simple classification and ideal if
printed graphs of the proposed chart are available. It
was not easy to communicate as writing or typing were
not possible.

Management of Cleft Lip and Palate 689

Right Left

Lip Partial cleft
Alveolus
Hard palate D
D
Total cleft

Fig. 57.2: Schuchardt and Pfeifer's symbolic classification

KERNAHAN AND STARK Fig. 57.3: Kernahan's striped 'V' classification
CLASSIFICATION (1958)

This is an embryological classification. The primary The classification uses a striped 'V' having
palate denotes the lip, alveolar ridge and the premaxilla
and the secondary palate refers to the hard and the numbered blocks to represent a specific area of the
soft palate which evolves from the maxillary shelves.
A. Clefts of primary palate only oral cavity.

• Unilateral Block 1 and 4 Lip
- Complete
- Incomplete. Block 2 and 5 Alveolus

• Median Block 3 and 6 Hard palate anterior to the
- Complete (premaxilla absent)
- Incomplete (premaxilla rudimentary) incisive fora men

• Bilateral Block 7 and 8 Hard palate posterior to
- Complete
- Incomplete incisive foramen

B. Clefts of secondary pala te only Block 9 Soft palate
• Complete
• Incomplete, or The boxes are shaded in areas where the cleft has
• Submucosal
occurred.
C. Clefts of primary and secondary palate
• Unilateral (right or left) MILLARD'S MODIFICATION OF THE KERNAHAN'S
- Complete or incomplete. STRIPED "VU CLASSIFICATION (FIG. 57.4)
• Median
- Complete or incomplete. Millard added two triangles over the tip of the "Y" to
• Bilateral denote the nasa 1 floor as shown in Figure 57.4.
- Complete or incomplete.
This increased the number of boxes to 11 as:
KERNAHAN'S STRIPED 'V' CLASSIFICATION • Block 1 and 5-Nasal floor
• Block 2 and 6-Lip
This is a symbolic classification put forward by • Block 3 and 7-Alvcolus
Kernahan (Fig. 57.3). • Block 4 and 8--Hard palate anterior to the incisive

foramen
• Block 9 and lQ-Hard palate posterior to the

incisive foramen
• Block l1-Soft pala te.

The unaffected areas were not shaded and the
shading of the triangles denoted the distortion of the
nose.

690 Textbook of Orthodontics

used arrows to indicate the direction of deflection in
complete clefts. He also placed a circle 12 under the
stem of the "Y" to represent the pharynx and a dotted
line from the Y to circle 12 reflecting the velo-
pharyngeal competence. Another circle 13 was also
added to represent the premaxilla, and the amount of
its protrusion was indicated by the dotted line with
an arrow.

Fig. 57.4: Millard'smodificationof the Kernahan's LAHSHAL CLASSIFICATION
striped 'V' classification
This is one of the simplest classifications and was
formulated byOkriens in 1987. Lahshal is a paraphrase
uf the anatomic areas affected by the cleft.

L Lip
A Alveolus
H Hard palate
S Soft pala te
H Hard palate
A Alveolus
L Lip
This classification is based on the premise that clefts
of lip, alveolus and hard palate can be bilateral while
clefts involving the soft palate are usually unilateral.
The areas involved in the cleft are denoted by the
specific alphabet standing for it. For example, LAH-
stands for cleft of right lip, alveolus and hard palate
and LA H S-L stand for cleft of right lip, alveolus,
hard palate and soft palate together with left cleft lip.

AMERICAN CLEFT PALATE ASSOCIATION'S
CLASSIFICATION (1962)

RL 1. Clefts of Pre-palate Right, left, extent in thirds
10 Cleft tip Right, left, extent in thirds
Unilateral Extent in thirds
11 Bilateral Small, medium, large
Median Right, left, medium
Fig. 57.5: Elsahy's modificationof striped 'V' classification Prolabium Extent in thirds
Congenital Scar
ELSAHV'S MODIFICATION OF THE KERNAHAN'S
STRIPED "V" CLASSIFICATION (FIG. 57.5) Clefts of the alveolar process
Elsahy modified the Striped "Y" further by double
lining the blocks 9 and 10 in the hard palate area and Unilateral Right, left, extent in thirds

Bilateral Right, left, extent in thirds

Median Extent in thirds, submucous

right, left, median

Cleft of pre-palate
Any combination of foregoing type:
Pre-palate protrusion

Management of Cleft Lip and Palate 691

Pre-palate rotation child/mother/and at times the family. As it is, the
Pre-palate arrest (median cleft) patient is afflicted by a number of problems associated
with the functions performed by the oral and nasal
2. Clefts of Palate Postcroantcrior in thirds cavities. The problems associated with cleft lip and/
Cleft soft palate Width (maximum in mm) palate patients are:
Extent None, slight, moderate,
marked PSYCHOLOGICAL
Palatal shortness Extent in thirds
The disfigurement caused by the condition is enough
Submucous cleft to cause psychological stress for the patient and the
family. The child often has to put up with staring,
Cleft of the hard palate Posteroanterior in thirds teasing, pity, etc. If this is not enough, due to the
Extent Width (maximum in mm) frequent visits to the various specialists the education
Right, left, absent suffers. He also fares badly in academics due to speech
Vomer attachment Extent in thirds and hearing problems often associated with such cases.
Submucous cleft
DENTAL (FIG. 57.6)
3. Cleft of Hard and Soft Palate
The clefts are generally associated with underdeve-
4. Clefts of Pre-palate and Palate loped maxilla and associated structures. The patient
Any combination of clefts described under clefts may present with some of the following features:
of prepalate and clefts of palate • Multiple missing teeth (most commonly the

INTERNATIONAL CONFEDERATION FOR maxillary lateral incisors).
PLASTIC AND RECONSTRUCTIVE SURGERY • Mobile premaxilla.
CLASSIFICATION (1968) • Anterior and / or posterior cross bites.
• Ectopically erupting teeth.
Group I • Impacted teeth.
• Supernumeraries.
Cleft of anterior primary palate • Poor alignment often predisposes to poor oral

a. Lip Right, left, both hygiene.
• Multiple decayed teeth.
b. Alveolus - Right, left, both • Periodontal complications.

Group 11 ESTHETIC (FIG. 57.7)

Clefts of anterior and posterior palate The patients with un-repaired clefts are badly disfi-
gured due to the nature of the deformity. Even
a. Lip Right, left, both following the closure of the cleft the maxilla remains
underdeveloped and the patient usually has a Class
b. Alveolus Right, left, both III skeletal profile with compromised esthetics.

c. Hard palate Right, left, both SPEECH AND HEARING

Group III Cleft lip and palate have definite speech problems.
These are sometimes associated with infections of the
Clefts of posterior secondary pala te middle ear. Since speech is learnt by the art of
imitation, if hearing is compromised so is the speech.
a. Hard palate Right, left Also, if the maxilla is underdeveloped the space for
maneuverability of the tongue gets decreased and
b. Soft palate - Median speech is likely to get affected.

PROBLEMS ASSOCIATED
WITH CLEFT LIP AND PALATE

The lack of awareness and superstition associated with
the condition has led the parents/relatives of the child
to create unnecessary psychological problems for the

Textbook of Orthodontics

Fig. 57.6: Dental problems associated with clefts

Fig. 57.7: Compromised esthetics MANAGEMENT OF CLEFT LIP AND PALATE

Children born with cleft lip and palate have a number
of problems that have to be solved for successful
rehabilitation. The complexity of the problem requires
that a number of specialists get together at various
stages of development for the eventual betterment of
the patient.

The treatment of cleft lip and palate involves the
total rehabilitation of the patient. It requires the
expertise of various specialists at different milestones
of life. No single specialist is fully equipped to handle
the cleft patient on his own, to attempt such an exercise
will lead to grave consequences for the esthetics of the
patient and would be an injustice to him/her.

The management of cleft cases requires team work
and patience. Each specialist has to be selfless and
work within his/her limits, involving specialists from
other fields as and when the need arises. Since the
orthodontist is involved with the patient from imme-
diately after birth till the permanent teeth have been
brought into functional and esthetically acceptable
position, he can be the team leader and help coordinate
the activities of other specialists.

Management of Cleft Lip and Palate 693

The management of the patient can be divided into
four distinct yet overlapping stages. The stages have
been created, based on the dentition of the patient.

Stage I Figs 57.9Aand B:Pre-surgicalorthopedics(A)Inbilateralclefts
The first stage extends from birth to 24 months. The the displaced premaxillais readapted to conformto the arch
orthodontist may be called upon to perform the (B) In unilateral clefts the displaced greater segment is
following two functions: readapted to conformto the arch
• Fabrication of a feeding plate or passive maxillary
posterior segments collapsed medially behind it (Fig.
obturator. 57.9B). Repositioning the segments before the initial
• Strapping of the premaxilla or other infant lip surgery made it easier to produce a more esthetic
lip with the first operation. This made the patients look
orthopedic procedures. much better at an early stage.
It is important to note that both the procedures are
optional and have inherent advantages and The use of such appliances has decreased over the
disadvantages. The procedures should be undertaken years, because even though they improved the
after evaluating the individual case. esthetics initially but the results over the years were
The feeding plate or the passive maxiIJary obturator not tha t encouraging.
(Fig. 57.8) is a passive prosthetic appliance that is used
to restore the palatal cleft and aid sucking. Ttalso helps lnfants with bilateral cleft need two types of
in preventing the maxillary arch from collapsing movements of maxillary segment; collapsed maxillary
further. The appliance is generally made of cold cure posterior segment must be laterally pushed and
or heat cure acrylic. Extraoral clasps are often used to pressure exerted against the maxilla to reposition it
aid retention of the appliance. These retention clasps posteriorly. Repositioning can be done either by an
or winged extensions can be held in place adjacent to appliance pinned to the segments, which applies a
the cheeks using micropore adhesive tape. contracting force or by the application of leucoplast
Infant orthopedic procedures were popular in late over the premaxillary segment (Fig. 57.10). A similar
1950's. They basically made use of removable force was also seen to have generated following an
orthodontic appliances to reposition the maxillary early lip repair.
segments in early infancy, before the initial flap
closure. 111 a unilateral cleft, the premaxillary segments Lip closure: Surgical correction of Up is done in early
are likely to be displaced facially adjacent to the cleft infancy as it is compatible with a good long-term
(Fig. 57.9A). Whereas in bilateral clefts, the premaxilla result. The common guidelines (as advocated by
is usually displaced significantly forward, with the Millard) is age 10 weeks, weight 10 pounds and
hemoglobin 10 gm%. Correcting the lip immediately
Fig. 57.8: Passive maxillaryobturatorwith after birth offers only psychological advantage to the
wings for retention parents and was popular in the 1960s. It involves a
greater risk of surgical morbidity, and long-term
esthetic results were found to be not as good.

694 Textbook of Orthodontics

appliances. The correction of cross bites at this stage
is debatable, as cross bite problems tend to reappear
and will require additional treatment in the mixed and
permanent dentition period.

The oral-hygiene instruction may be emphasized
upon and procedures undertaken to preserve the
existing tooth structu res.

Stage III

Fig. 57.10: Pre-surgicalorthopedics by This stage extends from 6 to 12 years of age, i.e. the
extraoralstrapping across the premaxilla mixed dentition stage. The orthodontist plays a major
role during this stage.
Many surgical techniques have been developed for • Arch expansion can be undertaken.
primary lip and nose closure. The rotation- • MaxiJIary protraction devices can be made use of.
advancement technique of Millard is most commonly • Fixed orthodontic treatment can be initiated, which
used. A discussion on surgical procedures is beyond
the scope of this book. will form the basis of the final alignment and
position of the teeth.
Surgical palate repair An intact palate aids the acquisi- Arch expansion can be undertaken using
tion of normal speech. At this time speech is develop- appliances such as the NiTi expander (Fig. 57.11A) or
ing rapidly. For ideal speech, therefore palate closure the quad helix (Fig. 57.11B). The NiTi molar rotator
between the age of 12 and 24 months is recommended. (Fig. 57.11e) may be used prior to the use of expansion
Some authors prefer to wait and recommend palatal appliances to correct the rotated first permanent
repair in the age group of 9 to 12 years. molars. A screw appliance can also be used.
Maxillary protraction appliances as in the reverse
The objectives of palatal surgery are to join the pull headgear is often used and has been found to be
cleftal edges, lengthen the soft palate, and repair the very effective in cooperative patients (Fig. 57.lID).
levator palatinii muscle. Alignment using fixed orthodontic appliances can
be initiated. The patient is referred for a bone graft
Stage 11 in the palatal region, before the eruption of the
permanent maxillary canine. If the canine can be
This stage extends from 24 months to 6 years of age. made to erupt through the graft, it adds to its
The period covers the primary dentition. The ortho- stability.
dontist plays the part of an observer and monitors the
development of the dentition. Generally no active Stage IV
orthodontic treatment is undertaken during this stage.
Adjustments may be made in the obturator to accom- This stage corresponds to the permanent dentition and
modate the erupting deciduous teeth. Cross bites final corrections are made during this stage (Fig. 57.12).
present at this stage can be corrected with either A reasonable amount of alignment along with esthetics
removable (split plate) or fixed (lingual arch) should be achieved. The canine, if not erupted is
exposed and brought into alignment. The arches are
aligned and the occlusion made to settle. Planning is
done regarding the need for orthognathic surgery.
Consultation with the oral and maxillofacial and
plastic surgeons is a must.

The retention planned should be permanent in
nature. Prosthetic rehabilitation can be accommodated
in the retention appliance- using fixed bridges or cast
partial dentures.

Management of Cleft Lip and Palate 695

Fig. 57.11A: A NiTi expander
Fig. 57.11B: A quad helix appliance (Photograph courtsey: Or Gautam Munjal, Chandigarh)

Fig. 57.11 C: A NiTi molar rotator is used before an expander

Textbook of Orthodontics

Fig. 57.110: Case treated using a face mask/reverse pull head-gear

Fig. 57.12: Treatment done during stage IV

Lip revision, nasal correction and the restoration FURTHER READING patient, Am J Orthod 1977;
of the nasophiltral angle can be undertaken following
the completion of all orthodontic treatment. 1. Barter G. The adult orthodontic
72:617-40.