Bridging Orthodontics and Surgery: An Algorithm for the Management of Transverse Discrepancies in Orofacial Clefts

Transverse maxillary deficiency is nearly universal in patients with cleft lip and/or palate (CLP) and represents a major determinant of occlusal function, surgical accessibility, and long-term stability. Despite established principles of rapid maxillary expansion and secondary alveolar bone grafting (SABG), considerable variability persists in appliance selection, timing, and sequencing of orthodontic and surgical interventions.

To develop a standardized, evidence-informed clinical algorithm for the management of transverse discrepancies in non-syndromic CLP patients, integrating orthodontic biomechanics with surgical timing considerations.

This study presents an algorithm-development framework based on structured clinical reasoning and synthesis of contemporary cleft care principles. Key variables incorporated into the decision pathway included cleft phenotype, presence of anterior segment collapse, type of posterior crossbite (relative versus absolute), dental development stage, and readiness criteria for SABG. Appliance selection (Hyrax, fan-type expander, differential opening expander), rate of activation, retention strategy, and post-graft orthodontic timing were systematically organized into a stepwise protocol designed for reproducibility across multidisciplinary cleft teams. This work is principally a structured review and synthesis of the existing literature, designed to organize established knowledge into an actionable clinical framework; no novel clinical concepts or techniques are introduced for the first time.

The presented algorithm provides a structured, clinically applicable framework to harmonize orthodontic and surgical management of transverse discrepancies in CLP patients, aiming to reduce treatment variability, enhance interdisciplinary coordination, and improve graft-related and occlusal outcomes.