In this second issue devoted to labio-maxillo-palatal clefts, we shall continue to emphasize the informational aspect that characterized the first issue. After presenting the specific fundamentals of management or clefts, we shall carefully consider the complementary disciplines that share in the overall care of cleft palate patients.

With an average frequency of 1/800 births in France, labio-maxillo-palatal clefts (LMPC) are among the most frequent congenital malformations. They raise functional, esthetic, psychological and socio-familial problems that must be managed with an interdisciplinary approach. Within the medical team, the dentist must, by way of prosthetic restorations, compensate for certain sequelae and deficiencies. According to the severity of the case and the success of the treatments, the typical restoration can be limited to replacing the missing lateral incisor, or the restoration may require undertaking comprehensive treatments involving a much more specialized arsenal of surgical and prosthetic procedures.

Labio-maxillary-palatal clefts, which are caused by fetal nasal buds failing to fuse with the maxillary bud, disrupt the ensemble of the structures that support and interact with the nose and upper jaw creating a rupture of balance that becomes an increasingly exacerbating vicious circle. In correcting these defects practitioners must effect a compromise between the need to re-unite separated parts – under as little tension as possible – and the need to preserve the interrupted potential for growth in the affected facial region. They must carry out this compromise in the double sense of topography and chronology.

Adhering to this therapeutic philosophy, the Nancy protocol closely associates orthopedic preparation and surgical treatment of patients to obtain:

     – high quality morphology,

     – an unblocked, sufficiently broad maxilla,

     – correct nasal breathing,

     – velo-pharyngeal competence.

We use a tibial periosteal graft to repair the oral cleft as an important element of our procedures.

Only competent centres are able to provide the full range of multi-disciplinary specialized therapies that cleft lip and palate rehabilitation requires. Despite some detail differences in conducting treatment, the agreed centres produced consensual treatment philosophy and observe equivalent therapeutic schemes. These sequences, to which orthodontics invariably contributes, are designed to favour the normal outcome of facial development and functions.

Beginning early in mixed dentition, orthodontic rehabilitation is designed to afford patients good dental occlusion through orthopaedic and orthodontic therapies. At the end of the growth period, orthodontics prepares for eventual final surgical and prosthetic repair.

We avoid extraction of permanent teeth as an adjunct to treatment because it has deleterious effect on final skeletal harmony. We prefer basic appliances for mechanical therapy, and after completion of active treatment, a prolonged retention. A trained orthodontist is able to complete the orthopaedic and orthodontic stages in cleft lip and palate repair if he fully understands and follows the general cleft lip and palate treatment scheme and effectively communicates with the competent rehabilitation team.