Reducing iatrogenic complications in the treatment of cleft lip and palate


Share / Export Citation / Email / Print / Text size:

Australasian Orthodontic Journal

Australian Society of Orthodontists

Subject: Dentistry, Orthodontics & Medicine


ISSN: 2207-7472
eISSN: 2207-7480





Volume / Issue / page

Volume 37 (2021)
Volume 36 (2020)
Volume 35 (2019)
Volume 34 (2018)
Volume 33 (2017)
Volume 32 (2016)
Volume 31 (2015)
Related articles

VOLUME 35 , ISSUE 2 (November 2019) > List of articles

Reducing iatrogenic complications in the treatment of cleft lip and palate

Andrew Savundra * / John Fricker

Citation Information : Australasian Orthodontic Journal. Volume 35, Issue 2, Pages 110-118, DOI:

License : (CC BY 4.0)

Published Online: 20-July-2021



All patients receiving orthodontic treatment with fixed appliances have a significantly higher risk of developing white spot lesions (WSLs), which are considered the most common iatrogenic complication of treatment. Cleft lip and/or palate (CLP) is a common craniofacial anomaly occurring in approximately one in 800 births. Patients affected by cleft lip and/or palate tend to have poorer oral hygiene and a greater risk of WSLs and caries than non-cleft sibling controls. Patients presenting with a cleft lip and/or palate also have a higher prevalence of molar-incisor hypomineralisation (MIH), which suggests that clinicians involved in the oral health management of cleft patients need to consider all available caries prevention protocols. Cases presenting with hypomineralised teeth create more difficulty in bonding attachments to affected enamel using an acid etch technique and a composite resin material due to the abnormal prism structure. The bond strength to hypomineralised enamel can be as low as two-thirds that of the bond strength to unaffected enamel, which may not be adequate for routine fixed appliance treatment. Furthermore, the removal of orthodontic brackets from hypomineralised enamel may lead to more severe damage to the affected teeth. Resin modified glass-ionomer cement (RMGIC), bonded after conditioning the enamel with polyacrylic acid, creates no resin tags as a result of a chemical rather than a mechanical bond. Therefore, there is less enamel loss during bracket debonding when compared with acid-etch preparation and composite resin bonding. Furthermore, in cases in which the quality of the enamel is deficient causing limits to the shear bond strength of the acid-etched composite resin, the chemical bonding action of RMGIC overcomes the lack of adherence and protects the enamel. RMGIC has cariostatic properties and clinical evidence supports the routine use of these adhesives for bonding in all fixed appliance cases as a strategy for reducing the incidence of white spot lesions and damage to the enamel during bracket debonding.

Content not available PDF Share



1. Bell JC, Raynes-Greenow C, Bower C, Turner RM, Roberts CL, Nassar N. Descriptive epidemiology of cleft lip and cleft palate in Western Australia. Birth Defects Res A Clin Mol Teratol 2013;97:101-8.

2. Ranta R. A review of tooth formation in children with cleft lip/ palate. Am J Orthod Dentofacial Orthop 1986;90:11-8.

3. Allam E, Ghoneima A, Eckert G, Tholpady S, Klene C, Kula K. Molar incisor hypomineralization in the permanent dentition of patients with unilateral or bilateral cleft lip and palate versus controls. Dent Oral Craniofac Res 2015;1.

4. Malanczuk T, Opitz C, Retzlaff R. Structural changes of dental enamel in both dentitions of cleft lip and palate patients. J Orofac Orthop 1999;60:259-68. [English and German]

5. Saldias-Vargas VP, Tovani-Palone MR, Moura-Martins AP, da SilvaDalben G, Ribeiro-Gomide M. Enamel defects in permanent first molars and incisors in individuals with cleft lip and/or palate. Revista de la Facultad de Medicina 2014;62:515-9.

6. Heitmüller D, Thiering E, Hoffmann U, Heinrich J, Manton D, Kühnisch J et al. Is there a positive relationship between molar incisor hypomineralisations and the presence of dental caries? Int J Paediatr Dent 2013;23:116-24.

7. Al-Dajani M. Comparison of dental caries prevalence in patients with cleft lip and/or palate and their sibling controls. Cleft Palate Craniofac J 2009;46:529-31.

8. Chapple JR, Nunn JH. The oral health of children with clefts of the lip, palate, or both. Cleft Palate Craniofac J 2001;38:525-8.

9. Wolff MS, Schenkel AB. The anticaries efficacy of a 1.5% arginine and fluoride toothpaste. Adv Dent Res 2018;29:93-7.

10. Chang HS, Walsh LJ, Freer TJ. Enamel demineralization during orthodontic treatment. Aetiology and prevention. Aust Dent J 1997;42:322-7.

11. Widmer RP, Mekertichian K. Paediatric dentistry--what’s new. A contemporary approach to the art and science of caries risk assessment. Ann Roy Australas Coll Dent Surg 1996;13:119-26.

12. Derks A, Katsaros C, Frencken JE, van’t Hof MA, KuijpersJagtman AM. Caries-inhibiting effect of preventive measures during orthodontic treatment with fixed appliances. A systematic review. Caries Res 2004;38:413-20.

13. Noble J, Cassolato S, Karaikos N, Wiltshire WA. Point of care. Preventive and interceptive measures for improving and maintaining good oral hygiene and cariogenic control in orthodontic patients. J Can Dent Assoc 2009;75:441-3.

14. Ogaard B, Rølla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop 1988;94:68-73.

15. Sudjalim TR, Woods MG, Manton DJ, Reynolds EC. Prevention of demineralization around orthodontic brackets in vitro. Am J Orthod Dentofacial Orthop 2007;131:705.e1-9.

16. Hadler-Olsen S, Sandvik K, El-Agroudi MA, Øgaard B. The incidence of caries and white spot lesions in orthodontically treated adolescents with a comprehensive caries prophylactic regimen--a prospective study. Eur J Orthod 2012;34:633-9.

17. Craig GC. How to handle white spot lesions associated with orthodontic treatment. Dental Outlook 2013:1-5.

18. Manton DJ. Diagnosis of the early carious lesion. Aust Dent J 2013;58 Suppl 1:35-9.

19. Yeoh ES, Le T, Maravilla J, O’Rourke V, He Y, Ye Q. Clinical evidence in the treatment of white spot lesions following fixed orthodontic therapy: a meta analysis. Aust Orthod J 2018;34:45-60.

20. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer SJ. Development of white spot lesions during orthodontic treatment: perceptions of patients, parents, orthodontists, and general dentists. Am J Orthod Dentofacial Orthop 2012;141:337-44.

21. Jälevik B. Enamel hypomineralization in permanent first molars. A clinical, histo-morphological and biochemical study. Swed Dent J Suppl 2001;149:1-86.

22. Garot E, Rouas P, D’Incau E, Lenoir N, Manton D, CoutureVeschambre C. Mineral density of hypomineralised and sound enamel. Bull Group Int Rech Sci Stomatol Odontol 2016;53:e33.

23. Farah RA, Swain MV, Drummond BK, Cook R, Atieh M. Mineral density of hypomineralised enamel. J Dent 2010;38:50-8.

24. Mast P, Rodrigueztapia MT, Daeniker L, Krejci I. Understanding MIH: definition, epidemiology, differential diagnosis and new treatment guidelines. Eur J Paediatr Dent 2013;14:204-8.

25. Gambetta-Tessini K, Mariño R, Ghanim A, Calache H, Manton DJ. Knowledge, experience and perceptions regarding Molar-Incisor Hypomineralisation (MIH) amongst Australian and Chilean public oral health care practitioners. BMC Oral Health 2016;16:75.

26. Shubha AB, Hegde S. Molar-incisor hypomineralization: review of its prevalence, etiology, clinical appearance and management. Int J Oral Maxillofac Path 2013;4:26-33.

27. Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res 2001;35:390-1.

28. Noble J, Karaiskos NE, Wiltshire WA. What additional precautions should I take when bonding to severely fluorotic teeth? J Can Dent Assoc 2008;74:891-2.

29. Gambetta-Tessini K, Mariño R, Ghanim A, Calache H, Manton DJ. Carious lesion severity and demarcated hypomineralised lesions of tooth enamel in schoolchildren from Melbourne, Australia. Aust Dent J 2018. [Epub ahead of print]

30. Buonocore MG. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res 1955;34:849- 53.

31. Schneider PM, Silva M. Endemic molar incisor hypomineralization: a pandemic problem that requires monitoring by the entire health care community. Curr Osteoporos Rep 2018;16:283-8.

32. Diedrich P. Enamel alterations from bracket bonding and debonding: a study with the scanning electron microscope. Am J Orthod 1981;79:500-22.

33. Yassaei S, Davari A, Goldani Moghadam M, Kamaei A. Comparison of shear bond strength of RMGI and composite resin for orthodontic bracket bonding. J Dent (Tehran) 2014;11:282-9.

34. Fowler PV. A twelve-month clinical trial comparing the bracket failure rates of light-cured resin-modified glass-ionomer adhesive and acid-etch chemical-cured composite. Aust Orthod J 1998;15:186- 90.

35. Fricker JP. A new self-curing resin-modified glass-ionomer cement for the direct bonding of orthodontic brackets in vivo. Am J Orthod Dentofacial Orthop 1998;113:384-6.

36. Mickenautsch S, Yengopal V, Banerjee A. Retention of orthodontic brackets bonded with resin-modified GIC versus composite resin adhesives—a quantitative systematic review of clinical trials. Clin Oral Investig 2012;16:1-14.

37. Summers A, Kao E, Gilmore J, Gunel E, Ngan P. Comparison of bond strength between a conventional resin adhesive and a resinmodified glass ionomer adhesive: an in vitro and in vivo study. Am J Orthod Dentofacial Orthop 2004;126:200-6.

38. Reynolds I. A review of direct orthodontic bonding. Br J Orthod 1975;2:171-8.

39. Gjorgievska E, Nicholson JW, Grcev AT. Ion migration from fluoride-releasing dental restorative materials into dental hard tissues. J Mater Sci Mater Med 2012;23:1811-21.

40. Mount GJ. An atlas of glass-ionomer cements: a clinician’s guide. London: Martin Dunitz, 1990.

41. Ngo H. Glass-ionomer cements as restorative and preventive materials. Dent Clin North Am 2010;54:551-63.

42. Sidhu SK, Nicholson JW. A review of glass-ionomer cements for clinical dentistry. J Funct Biomater 2016;7:16.

43. Mount GJ, Patel C, Makinson OF. Resin modified glass-ionomers: strength, cure depth and translucency. Aust Dent J 2002;47:339-43.

44. Hengtrakool C, Pearson GJ, Wilson M. Interaction between GIC and S. sanguis biofilms: antibacterial properties and changes of surface hardness. J Dent 2006;34:588-97.

45. Mickenautsch S, Mount G, Yengopal V. Therapeutic effect of glassionomers: an overview of evidence. Aust Dent J 2011;56:10-5; quiz 103.

46. Pascotto RC, de Lima Navarro MF, Capelozza Filho L, Cury JA. In vivo effect of a resin-modified glass ionomer cement on enamel demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop 2004;125:36-41.

47. Justus R. Deproteinization of tooth enamel surfaces to prevent white spot lesions and bracket bond failure: A revolution in orthodontic bonding. APOS Trends in Orthodontics 2016;6:179-84.

48. McLean JW, Wilson AD. Glass ionomer cements. Br Dent J 2004;196:514-5.

49. Nicholson JW. Adhesion of glass-ionomer cements to teeth: A review. Int J of Adhesion and Adhesives. 2016;69:33.

50. Fjeld M, Øgaard B. Scanning electron microscopic evaluation of enamel surfaces exposed to 3 orthodontic bonding systems. Am J Orthod Dentofacial Orthop 2006;130:575-81.

51. Ryf S, Flury S, Palaniappan S, Lussi A, van Meerbeek B, Zimmerli B. Enamel loss and adhesive remnants following bracket removal and various clean-up procedures in vitro. Eur J Orthod 2012;34:25-32.

52. Pus MD, Way DC. Enamel loss due to orthodontic bonding with filled and unfilled resins using various clean-up techniques. Am J Orthod 1980;77:269-83.

53. Thompson RE, Way DC. Enamel loss due to prophylaxis and multiple bonding/debonding of orthodontic attachments. Am J Orthod 1981;79:282-95.

54. Krell KV, Courey JM, Bishara SE. Orthodontic bracket removal using conventional and ultrasonic debonding techniques, enamel loss, and time requirements. Am J Orthod Dentofacial Orthop 993;103:258-66.

55. Claudino D, Kuga MC, Belizário L, Pereira JR. Enamel evaluation by scanning electron microscopy after debonding brackets and removal of adhesive remnants. J Clin Exp Dent 2018;10:e248-51.

56. Cochrane NJ, Lo TW, Adams GG, Schneider PM. Quantitative analysis of enamel on debonded orthodontic brackets. Am J Orthod Dentofacial Orthop 2017;152:312-9.

57. Tüfekçi E, Merrill TE, Pintado MR, Beyer JP, Brantley WA. Enamel loss associated with orthodontic adhesive removal on teeth with white spot lesions: an in vitro study. Am J Orthod Dentofacial Orthop 2004;125:733-9.

58. Ireland A, Hosein I, Sherriff M. Enamel loss at bond-up, debond and clean-up following the use of a conventional light-cured composite and a resin-modified glass polyalkenoate cement. Eur J Orthod 2005;27:413-9.

59. Al Shamsi AH, Cunningham JL, Lamey PJ, Lynch E. Threedimensional measurement of residual adhesive and enamel loss on teeth after debonding of orthodontic brackets: an in-vitro study. Am J Orthod Dentofacial Orthop 2007;131:301.e9-15.