Orthodontic care of a child with cleft Lip and Palate
How does cleft lip/palate affect the teeth?
A cleft of the lip, gum (alveolus), and/or palate in the front of the mouth can produce a variety of dental problems. These may involve the number, size, shape, and position of both the baby teeth and the permanent teeth. The teeth most commonly affected by the clefting process are those in the area of the cleft, primarily the lateral incisors. Clefts occur between the cuspid (eye tooth) and the lateral incisor. In some cases the lateral incisor may be entirely absent. In other cases there may be a "twinning" (twin = two) of the lateral incisor so that one is present on each side of the cleft. In some cases the incisor, or other teeth, present may be poorly formed with an abnormally shaped crown and/or root. Teeth in the area of the cleft may also be displaced, resulting in their eruption into abnormal positions. Occasionally the central incisors on the cleft side may present with some of the same problems as the lateral incisor.
What does this mean for future dental care?
A child with a cleft lip/palate requires the same regular preventive and restorative care as the child without a cleft. However, since children with clefts may have special problems related to missing, malformed, or malpositioned teeth, they require early evaluation by a Orthodontist specialist who is familiar with the needs of the child with a cleft.
Early Orthodontic Care
With proper care, children born with a cleft lip and/or palate can have healthy teeth. This requires proper cleaning, good nutrition, and fluoride treatment. Appropriate cleaning with a small, soft-bristled toothbrush should begin as soon as teeth erupt. Oral hygiene instructions and preventative counselling can be provided by a paediatric Orthodontist specialist or a general Orthodontist specialist. Many Orthodontist specialists recommend that the first dental visit be scheduled at about one year of age or even earlier if there are special dental problems. The early evaluation is usually provided through the Cleft Palate Team. Routine dental care with a local Orthodontist specialist begins at about three years of age. The treatment recommended depends upon many factors. Some children require only preventative care while others will need fillings or removal of a tooth. Of particular importance is the substance taken in the feeding bottle. Any liquid contains a sugar will cause damage to the teeth especially when taken at bedtime. It is recommended that bottle feeding stops at 14-16 month old baby.
The first orthodontic evaluation may be scheduled at the age 6-8 years old. The purpose of this visit is to assess facial growth, particularly the growth of the jaws. And make plans for the child's short and long-term dental needs. For example, if a child's upper teeth do not fit together (occlude) properly with the lower teeth, the orthodontist may suggest an early period of treatment to correct the relationship of the upper jaw to the lower jaw. At age 10-12 years old just before the eruption of the cuspid (eye tooth) the second phase of orthodontics will start by preparing the dental arches for bone grafting to close the cleft using expansion appliance. The final orthodontic stage will be done 3-6 months after performing the bone graft to complete alignment of the teeth.
Coordinated Orthodontic-Surgical Care
Coordination of treatment between the surgeon and dental specialist is important since several procedures may be completed during the same anaesthesia. Restorations or dental extractions can be scheduled at the same time as other surgery.
Coordination between the surgeon and the orthodontist becomes most important in the Orthodontic care of a child with cleft Lip and Palate.
Bone Grafting the Cleft Maxilla
Bone grafting in the dental ridge of the upper jaw (maxilla) is now standard, reliable treatment for patients with facial clefts. Bone grafting is an operation which involves taking a small amount of bone from one place (usually the hip, head, ribs, or leg) and placing it in the area of the cleft near the teeth. The procedure is employed to accomplish the following four goals:
1. To provide support for unerupted teeth and teeth next to the cleft.
2. To provide support for the lip and nose and to improve symmetry.
3. To form a continuous upper gum(alveolar)ridge, creating a more natural appearance and stability to the ridge.
4. To improve the stability of the front part of the roof of the mouth (premaxilla), if a bilateral cleft is present. Bone grafting is a useful procedure and is most successful in patients under 11 years of age . The overall erupting varies from child to-child but usually is completed between the ages of 10 and 13. Older patients may benefit from a bone graft but have less chance of total success. If the patient is a smoker, has a systemic disease such as diabetes, or has poor oral hygiene, the risk that the graft may fail increases even more. Once the bone graft has been placed, there are three options that may be considered to replace any missing teeth in the area of the graft. These are:
1) Moving adjacent teeth into the bone graft;
2) Prosthetic replacement (dental bridge); or
3) Orthodontic metallic bone implants.
The best option for an individual patient will be chosen by the dental specialists on the cleft and palate team.
Missing Tooth Fact Sheet for a child with cleft lip and palate
Patients with cleft lip or cleft lip and palate are often born with a missing tooth, most often the lateral incisor (immediately next to the front central incisor). This may occur unilaterally or bilaterally, and special planning is needed to solve the functional and cosmetic problems the absence creates.
Who will be involved in dealing with the missing tooth?
Several dental specialists will be most important in planning treatment. Orthodontists align improperly placed teeth, while prosthodontists can replace missing teeth in a variety of ways. Oral and maxillofacial surgeons perform surgery to the teeth, mouth, and surrounding areas of the head and face. Coordinated planning by all specialists involved is necessary for the best result.
What role does the orthodontist play in replacing a missing tooth?
The large majority of patients with clefts will require full orthodontic treatment, especially if the cleft has passed through the tooth-bearing ridge. Goals of treatment will be to line up the teeth in the upper arch, create an arch form that is harmonious with the lower dental arch, and line up the midline of the upper arch with that of the lower arch. When a tooth is missing, the upper midline is usually shifted, so this must be corrected. A space is often opened up and maintained for later replacement of the missing lateral incisor.
During orthodontic treatment, an artificial tooth may be attached to the orthodontic wire as a temporary replacement for the lateral incisor. When the braces are removed, a removable retainer with an artificial tooth serves to maintain the space and improve speech and appearance until a definitive restoration is made.
Is the missing tooth always replaced?
In many instances, the space for the lateral incisor will be orthodontically and/or surgically closed by moving the canine forward into the space normally occupied by the lateral incisor. This will then require modification of the canine to make it appear as a lateral incisor. This may be accomplished by adding plastic or porcelain filling material or a porcelain crown to reshape its appearance after the orthodontic treatment at 14-16 years old.
What options are available for permanent replacement of the lateral incisor?
Treatment options for the permanent replacement of the lateral incisor depend upon whether or not the cleft has been repaired with a bone graft. In a non-grafted dental arch, there are two options for replacement:
First, a removable partial denture may be used to replace the missing tooth. While this option may be made to look acceptable, it has several disadvantages. The removable prosthesis must cover most of the palate for support. This may cause irritation on the roof of the mouth or at the gumline where it rests. Many patients also object to the extra bulk and removable nature of the partial denture and report that it feels unnatural. This type of prosthesis is best as a temporary replacement as described above.
The second option in a patient without a bone graft is a fixed bridge. The missing tooth is restored with an artificial one connected to crowns (caps) on teeth on each side of the cleft. Because there is loss of supporting bone at each tooth on either side of the cleft, two teeth on each side must usually be crowned to give adequate support to the bridge. This type of prosthesis is not removable. Its contours and appearance look and feel more natural than a removable partial denture. However, it does require grinding down the supporting teeth in order to crown them and connect them to the artificial tooth. Cleaning between the crowned teeth also becomes more difficult since they are connected.
Can a fixed bridge be made immediately after braces?
In a teenager or young adult, the nerves and blood vessels in the tooth pulps are rather large. Drilling down these teeth for crowns may expose the pulps and require root canal therapy. Therefore, this type of treatment must usually wait until adulthood when the pulps are smaller.
What options are available for a patient who has had a bone graft?
Bone grafting the cleft site in the upper jaw creates a more normal arch and eliminates special restorative considerations relative to the cleft. A conventional fixed bridge as described above may be used. In many cases, only one tooth on either side of the cleft needs to be crowned, since the graft has stabilized the arch and added bone. If the teeth that hold the bridge are not otherwise in need of restoration, a resin-bonded fixed bridge may be chosen. This type of bridge requires much less tooth reduction of adjacent teeth, and there is no danger of nerve involvement. A porcelain replacement tooth is held in place by metal extensions cemented to the backs of the adjacent teeth. This is a more conservative restoration with regards to tooth preparation but still requires connecting teeth together.
The most natural, lifelike restoration for a patient with a bone graft is a single porcelain crown attached to an osseointegrated dental implant. This involves a surgical procedure where titanium screws the size and shape of a tooth's root is inserted into the bone at the site of the missing tooth. It is covered by the gum for approximately six months while the bone bonds to the implant surface. Then the implant is uncovered and an artificial tooth (crown) is attached. While this procedure does require minor surgery, it does not require cutting down or crowning any other teeth. Cleaning is also easier because the replacement tooth is not connected to any other teeth. This restoration does give the most natural result but does require that sufficient bone is present in order to hold the screw.
Finding the best treatment for a missing tooth requires cooperation and planning among several specialists
A variety of options for successful tooth replacement are available
Patients with missing teeth and/or their parents should thoroughly discuss treatment options with the multidisciplinary team before making a decision.
Compiled by Dr E Ghabrial, Prof. J Terblanche & Dr A vd Merwe UP Craniofacial deformeties& facial cleft team November 2000