Orthodontists are involved with the study and guidance of the growth and development of the face, and dentition of the child with a cleft or craniofacial anomaly from birth to maturity. Their role includes diagnosis of changing facial morphology and function due to treatment and growth. They provide orthodontic and orthopedic treatment and general expertise for consultation with all of the other members of the cleft and craniofacial team. Due to the long-term treatment required for the majority of these patients, different phases of active treatment, interspersed with periods of retention or no treatment, will be necessary.

1. Prenatal - none
2. Neonatal
   1. Pre-surgical infant orthopedics is sometimes used to reposition the segments of the cleft maxilla prior to lip repair. This can vary in complexity from lip taping to narrow the cleft, to a bonnet with elastic to ventroflex a protruding premaxilla, to more complex pinned appliances.
   2. These appliances can make lip closure easier. While this short-term benefit is clear, long term effects are unclear and controversial.
   3. Some clinicians use orthopedic appliances to alter the appearance of the nose and/or columella to improve the shape prior to lip repair.
3. Infant
   When the primary teeth begin to erupt, the parents are advised as to the possibility of dental irregularities, particularly an incisor or supernumerary tooth erupting into the palate. The long-term sequence of treatment is outlined in general terms.
4. Toddler
   No specific treatment is indicated, but digit habits and functional shifts may be addressed. Communication with the primary care dentist/pedodontist is established and future concerns outlined.
5. Preschool
   1. In some cases, the maxilla may be expanded in order to improve dental function, eliminate functional shifts, to provide access for restorative care to carious teeth impacted in the cleft site, and/or to improve the nasal airway. However, long term retention is needed to maintain the expansion.
   2. Oronasal fistulae are sometimes a concern because of liquids escaping through the nose. The anterior part of the cleft may have become hidden as the maxillary segments moved together after lip repair, and this area may not have been repaired during palatoplasty. Consequently, palatal expansion may expose this oronasal communication. Surgical closure is often difficult, and the orthodontist may elect to use an obturator to close off the fistula.
   3. A reverse pull headgear may be considered to protract the maxilla and maintain normal jaw relations. This is an effective treatment modality but requires considerable compliance on the part of the patient. Overall success is also uncertain due to the difficulty in anticipating future jaw growth when trying to compensate for inadequate maxillary growth.
6. School-Aged
   1. Fixed appliance therapy usually occurs in the mixed dentition between the ages of 7 and 9 years, with the goal of preparing for alveolar bone grafting.
   2. This phase usually involves aligning malpositioned incisors and expanding the maxillary arch to an appropriate relationship with the lower dental arch. When this is complete, an alveolar bone graft is placed and any oronasal fistulae closed. Maintenance of expansion with a palatal bar or removable appliance is required for some time since the grafted maxilla is unable to maintain the corrected arch form.
   3. Reverse pull headgear therapy may be initiated or continued during this time period.
7. Adolescents
   1. When the permanent teeth have erupted, definitive orthodontic treatment begins.
   2. Treatment may involve surgical or orthopedic repositioning of the jaws to optimize jaw relations and occlusion. Close cooperation between the orthodontist, surgeon, prosthodontist (if necessary), and general dentist is required during this time.
8. Adults
   Adults generally require the same treatment as children and adolescents with some possible exceptions. Since adults have completed growth, no possibility exists for influencing jaw growth through orthopedics. Additional or more extensive surgery may be required to achieve the same result. Alveolar bone grafts are less successful in adults, and thus may not be indicated if a graft would not carry significant benefits. Otherwise, a properly treated patient should have the same dental status as a non-cleft person. All aesthetic and functional goals can and should be addressed.
9. Record keeping
   This is an important part of the orthodontist's role on the cleft and craniofacial team, as it is necessary for assessment of treatment results.
   1. Infant - Photographs should be taken regardless of any treatment. Casts should be made prior to and following any pre-surgical orthopedic treatment. Infant casts are important to assess the wide variability of cleft morphology and to compare the results of different treatments over time as growth occurs.
   2. Preschool - Records taken during this time period depend upon treatment rendered. If palatal expansion is done, casts, photos, and a posteroanterior cephalogram are important to assess the result of treatment.
   3. School aged - Full or orthodontic records should be taken prior to any orthodontic intervention, including incisor alignment and palatal expansion. These records should include, but are not limited to casts, photos, radiographs (panoramic, occlusal, periapical, and lateral/submentovertex/posteroanterior cephalograms), and clinical examination. Further, appropriate records, such as casts and photos, should be taken after treatment.
   4. Adolescents - Full orthodontic records as above should be taken before and after definitive orthodontic treatment. Progress records should be taken before and after orthognathic surgery, and more often as necessary.
   5. Adult - Full records should be taken as described above.

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