The scope of the practice involves pre-surgical infant orthopedics for the cleft patient, phase I  treatment and preparation for alveolar bone grafting, and comprehensive orthodontic treatment, including orthognathic surgical planning and preparation. Weekly team meetings, didactic and case-based conference, literature review are integral to the applicant. Upon completion of the program, a certificate in cleft lip and palate orthodontics from The Department of Orthodontics, University of Mashhad is awarded.

This  course will provide the applicant with experience in the following clinical areas:

1. Newborn assessment for need of early intervention
2. Presurgical orthopedics (Nasoalveolar Molding) for infants born with cleft lip and palate if needed to align segments
3. Growth and orthodontic management from the primary through adult dentition and attainment of skeletal maturity.
4. Surgical/orthodontic treatment planning, pre- and post-surgical orthodontic management, surgical splint design and construction, and insertion of surgical fixation splints in the operating room.

The focus of this short course of orthodontics includes cleft lip and palate, and other craniofacial anomalies, dentofacial deformities, craniofacial surgery, orthognathic surgery, distraction osteogenesis, nasoalveolar molding and special care orthodontics.

The goal of the program is to train individuals to take an active role on a cleft and craniofacial treatment team and to be proficient in all growth and development and orthodontic management aspects.

The applicant participates in craniofacial and cleft conference with specialist in nursing, ENT, craniofacial surgery, speech, neurosurgery, genetics, prosthodontics, social work and psychology. Interdisciplinary treatment planning sessions are scheduled routinely to examine patients with the surgeons and other specialty team members as needed.

Children born with clefts and other craniofacial anomalies are provided optimum care when they are assessed and treated by a team of specialists with expertise in a variety of areas. Health care specialties involved with the care of clefts and other craniofacial anomalies include audiology, genetics, nursing, oral and maxillofacial surgery, orthodontics, otolaryngology/head and neck surgery, pediatric dentistry, plastic surgery, psychology and clinical social work, and speech-language pathology.

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.

A. Prenatal — none

B. 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.

C. 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.

D. 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.

E. 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.

F. 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.

G. 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.

H. 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.

The Core Curriculum is not intended to cover all possible aspects of cleft and craniofacial management. Rather, it is intended to provide an outline of services that are appropriate for most children affected by these disorders.

The Core Curriculum is divided into two broad sections. The first covers the basics of interdisciplinary team care, classification of craniofacial anomalies, craniofacial development and etiology. The second section covers the role of each discipline in the care of a patient with a cleft or craniofacial anomaly. It is organized by patient age, within each discipline, and covers the essential aspects and knowledge bases that are essential for providing adequate care. Just as in a team there may be overlap between specialists in their observations, core knowledge and treatment expertise, this core curriculum reflects some overlap between specialties in these areas.