www.PRSJournal.com 355 S urgical maneuvers for cleft correction in the developing child are known to be associated with maxillary hypoplasia due to disruption of growth centers and scar tissue formation. 1 How- ever, the long-term effect of adjunctive nonsurgi- cal manipulation has received minimal attention. Cleft patients in developed countries undergo multiple years of orthodontia, usually beginning around the age of 6, with completion only at full skeletal maturity. One of the largest orthodontic movements involves the technique of canine sub- stitution, in which a hemi-arch of dentition begin- ning with the canine is moved anteriorly to close the dental space left by a cleft-related missing lat- eral incisor. Disclosure: The authors have no financial inter- ests, including products or devices, associated with this article. There are no commercial associations that might pose or create a conflict of interest with information presented in this article. All sources of funds supporting the completion of this article are under the auspices of the University of California Los Angeles. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000436857.63021.f0 Justine C. Lee, M.D., Ph.D. Ginger C. Slack, B.S. Ryann Walker, B.A. Lindsay Graves, B.A. Sandra Yen, B.A. Jessica Woo, B.A. Rishal Ambaram, B.A. Martin G. Martz, D.D.S., M.S. Henry K. Kawamoto, Jr., M.D., D.D.S. James P. Bradley, M.D. Los Angeles, Calif. Background: Cleft lip and palate surgery in the developing child is known to be associated with maxillary hypoplasia. However, the effects of nonsurgical manipulations on maxillary growth have not been well investigated. The au- thors present the contribution of orthodontic dental space closure with canine substitution to maxillary hypoplasia and the need for orthognathic surgery. Methods: Cleft lip/palate and cleft palate patients older than 15 years of age were reviewed for dental anomalies, orthodontic canine substitution, and Le Fort I advancement. Skeletal relationships of the maxilla to the skull base (SNA), mandible (ANB), and facial height were determined on lateral cepha- lograms. Logistic regression analyses were performed to estimate odds ratios. Results: Ninety-five patients were reviewed (mean age, 18.1 years). In 65 pa- tients with congenitally missing teeth, 55 percent with patent dental spaces re- quired Le Fort I advancement. In contrast, 89 percent who underwent canine substitution required Le Fort I advancement (p = 0.004). Canine substitution is associated with a statistically significant increase in maxillary retrognathia when compared with dental space preservation on lateral cephalograms (mean SNA, 75.2 and 79.0, respectively; p = 0.006). Adjusting for missing dentition, logistic regression analyses demonstrated that canine substitution is an inde- pendent predictor for orthognathic surgery (OR, 6.47) and maxillary retrusion defined by SNA < 78 (OR, 8.100). Conclusions: The coordination of orthodontia and surgery is essential to cleft care. The authors report a strong association between orthodontic cleft closure using canine substitution with maxillary hypoplasia and subsequent Le Fort I advancement, and suggest systematic criteria for management of cleft-related dental agenesis. (Plast. Reconstr. Surg. 133: 355, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. From the Division of Plastic and Reconstructive Surgery, University of California Los Angeles David Geffen School of Medicine; and Section of Orthodontics, University of Cali- fornia Los Angeles School of Dentistry. Received for publication June 4, 2013; accepted August 7, 2013. Presented at the 92nd American Association of Plastic Surgeons Meeting, in New Orleans, Louisiana, April 20 through 23, 2013, and the 58th Plastic Surgery Research Council Meeting, in Santa Monica, California, May 2 through 4, 2013. Maxillary Hypoplasia in the Cleft Patient: Contribution of Orthodontic Dental Space Closure to Orthognathic Surgery PEDIATRIC/CRANIOFACIAL