Cleft lip and palate orthodontics

Cleft-related orthodontic care in the UK is managed through regional NHS specialist cleft networks under the NHS England Cleft Lip and Palate specification. Orthodontic treatment that is part of the cleft care pathway — including arch expansion before bone grafting, pre-surgical orthodontics, and comprehensive brace treatment — is generally NHS-funded throughout childhood and into young adulthood. Adults requiring orthodontics as part of an ongoing cleft care plan may also qualify. The treating cleft orthodontist should clarify funding status at the outset of any new phase of treatment, particularly for adults who no longer have routine NHS orthodontic entitlement.

An alveolar bone graft is a surgical procedure that places bone material — usually taken from the hip (iliac crest) — into the cleft gap in the upper gum ridge (alveolus) where bone is absent. The graft provides a bony bridge across the cleft that supports the eruption of teeth adjacent to the cleft site, particularly the upper canine, and creates structural continuity of the arch. In the UK, alveolar bone grafting is typically timed between ages 9 and 11, before the upper canine erupts — a period often called secondary alveolar bone grafting. Orthodontic expansion of the upper arch is usually completed before grafting to open the cleft site and improve access. After successful grafting, the canine can erupt into or be guided orthodontically into the newly created bone.

The majority of children with cleft lip or palate will require orthodontic treatment at some stage, though the extent and timing vary according to the type of cleft, the dental development, the outcome of surgery, and the child's growth. Children with cleft palate only (without cleft lip) may have less dental irregularity and simpler orthodontic needs. Children with unilateral or bilateral cleft lip and palate typically have more significant arch width deficiency, displaced or missing teeth adjacent to the cleft, and Class III skeletal tendency — all of which usually require comprehensive orthodontic management. An orthodontic review within the cleft MDT from the mixed dentition stage ensures that each child's needs are individually assessed and a timely plan is in place.

Some adults with cleft lip or palate can have dental implants, but careful planning is required. The alveolar bone in the cleft region may be of reduced volume and density even after bone grafting — a cone beam CT (CBCT) scan is needed to assess bone quantity and quality before implant placement. Prosthetic teeth adjacent to the cleft (particularly the lateral incisor, which is commonly absent or malformed in cleft cases) are often replaced with implants after orthodontic treatment has redistributed the available space optimally. Restorative dentists and oral surgeons working within the cleft MDT provide the most reliable assessment of implant feasibility for any given patient.

Cleft care requires staged orthodontics because different treatment goals are only achievable at specific developmental windows. Primary dental stage (birth to 6): monitoring and any infant pre-surgical orthopaedics. Mixed dentition (6–11): early expansion for arch width, monitoring eruption, preparing for bone grafting. Pre-graft phase (9–11): expansion, space management for the canine. Post-graft and adolescent phase (11–17): comprehensive fixed brace treatment to align all teeth, coordinate arches, and prepare for any surgical planning. Post-growth (17+): orthognathic surgery if indicated, followed by post-surgical orthodontics and restorative planning. This sequence is governed by growth, eruption, surgery timing, and speech rehabilitation — treating at the wrong stage is less effective or can interfere with other aspects of care.

Yes — adults with cleft-related dental problems can have orthodontic treatment, though the planning is often more complex than standard adult orthodontics. Adults may present with residual crossbites, anterior space deficiency, missing teeth, bone deficiency at the cleft site, and jaw discrepancies that were managed non-surgically in childhood but may now require reassessment. Some adults have not had orthodontic treatment since childhood and have experienced relapse or new dental changes. The approach usually involves a combined orthodontic-restorative or orthodontic-surgical team. Adults considering treatment should seek a specialist orthodontist with experience in cleft-related treatment, as many of these cases are outside the scope of routine private adult orthodontics.

The most frequently encountered dental issues in cleft-affected individuals include: hypodontia (congenitally missing teeth, particularly the lateral incisor adjacent to the cleft), supernumerary teeth (extra teeth on either side of the cleft), ectopic canine position, upper arch width deficiency causing posterior crossbite, Class III skeletal tendency (mandible appearing relatively forward due to upper jaw undergrowth following surgery), impacted teeth, delayed dental eruption, and enamel hypoplasia in teeth adjacent to the cleft. The lateral incisor adjacent to the cleft is absent in approximately 50% of cases and present but malformed or compromised in many others — this is a key restorative and orthodontic planning decision, as the options include closing the space orthodontically, building up a retained malformed tooth, or placing an implant after growth completion.