Published: June 20, 2007
Updated: June 20, 2007
Most of us are aware of the role the orthodontist plays in straightening children's teeth through the use of "braces" and "retainers." In a broader sense, orthodontics is the specialty area of dentistry that deals with the growth and development of the face, jaws, and dental arches (teeth). Because clefts often affect parts of the mouth which play roles in the growth of teeth, the orthodontist plays a very special role on your cleft palate team.
The child with a cleft lip or palate may be observed or treated by the orthodontist at several points along the road to adulthood. In some cases, the expertise of the orthodontist will actually be called into play before the plastic surgeon operates. For example, with some babies, it is necessary to align the gums of the upper jaw before the plastic surgeon can operate on the cleft lip. In these cases, the orthodontist makes a mold or impression of the upper jaw and designs an appliance to bring the upper tooth arch into alignment. Such appliances may involve headgear with straps that fit around the outside of the face and head, or they may be smaller appliances, pinned into the palate for several weeks before surgery. In either case, the orthodontist works closely with the surgeon to mold the front bones of the upper jaw into a position that permits surgical correction of the cleft lip.
As the child grows and the baby teeth erupt ("come in"), continuing orthodontic observation is needed, and some limited orthodontic treatment may be required. This may involve moving a few rotated teeth which are interfering with biting and chewing, or fitting the child with an appliance to cover a hole in the palate that interferes with speech. The contribution which the orthodontist can make to the speech-learning process is another indication of the advantages offered by the team approach to treating cleft lip and cleft palate.
For the most part, though, the bulk of orthodontic work with cleft conditions takes place after the permanent (adult) teeth erupt. Correcting rotated teeth and cross-bite, and aligning the upper and lower teeth for adequate chewing and improved appearance are some of the goals of orthodontic treatment. Where there are missing teeth, orthodontic treatment can either close spaces or prepare the teeth for later placement of selected false teeth (fixed or removable). The appliances supporting these "replacement teeth" are made by the general dentist/prosthodontist, another member of the cleft palate team.
As the growth and development specialist for the facial area, the orthodontist consults with the surgeon about the need and best time for certain surgical procedures.
In some children, the missing bone in the cleft of the upper dental arch requires replacement by a bone graft. The time to do this operation depends, in part, on the development of the permanent teeth in adjacent areas. At times, the bone graft is done before the eruption of a permanent tooth. This can allow the new tooth to "come in" through the new bone which provides support for the tooth. Otherwise, the tooth would eventually be removed due to the lack of bone support.
In the growing child with a cleft, the upper jaw does not always grow as much as the lower jaw. The resulting differences in the upper and lower dental arches can present problems in appearance, speech, or chewing. Sometimes, orthodontic treatment alone can correct the problem. In other cases, however, the child may require a combined orthodontic and surgical treatment for adequate alignment of the jaws and teeth. When required, the surgical procedure is usually done in the late teenage years. In this orthognathic surgery, a deficient upper jaw can be moved forward, or a lower jaw that has overgrown the upper jaw can be set back appropriately.
In all of these instances, decisions about the timing and nature of surgery are based largely on the opinions of all consulting members of the cleft palate team during conferences. The treatment plan for your child is individualized according to his or her specific growth and development pattern.
When maxillofacial or oral surgery is required, the surgeon can rearrange misshapen jaws so that they can work normally together for speech and eating. These services may also be required later in childhood or during young adulthood.
An example of one situation in which the services of the plastic, maxillofacial, and oral surgeon might be called into play on the cleft palate team is with children who are born with clefts but also demonstrate an underdevelopment of the upper jaw. If this is severe, the upper lip and mid-face may appear to be depressed or flat, or the lower jaw may seem to be very prominent. The members of the team can devise an appropriate treatment plan for correction of this functional and aesthetic deformity, surgery might deal with repositioning the upper jaw (MAXILLA) and the lower jaw (MANDIBLE) to correct functional problems and to achieve facial balance.
While healthy teeth are important to all children, they are even more important for a child with a cleft because good healthy teeth assist in the process of treating cleft lip and cleft palate. Obviously, healthy teeth affect our appearance and our capabilities to chew and speak, but they also play vital roles in facilitating oral surgery and orthodontics in the treatment of children with cleft. In addition healthy teeth are required for the placement of appliances which may be needed to help these children with speech. Regular dental checkups should begin when your child reaches the age of two or three.
Regardless of the type of cleft, children will get most of their primary (baby) teeth. Even if the cleft involves the alveolar ridge (gums), the teeth should come in, though there may be a space between them. On the other hand, permanent (adult) teeth are frequently missing in these children, especially in the region of the cleft. In this region, your child's dentist, orthodontist, and oral surgeon will work hard to treat and preserve the teeth that do come in, because losing these teeth will lead to further deterioration of the bone in the area. If some permanent teeth in the cleft region are missing, they may be replaced temporarily. Once growth of the jaws is completed and orthodontic movement of the teeth is finalized, those "temporary teeth" can be replaced with a permanent bridge or a removable partial denture.
As important as professional dental care is to your child, the dental care given at home plays an even greater role. It is best to limit between-meal snacking and sugary sweets, but even healthful foods can cause cavities. It is vitally important that you clean your child's teeth every evening at bedtime, and whenever possible after meals, as well. This will take more time with a child who has a cleft, but your awareness of the importance of healthy teeth to your child may help you to be consistent about it.
You should begin this process as soon as your child's first tooth appears in his/her mouth. Use a fluoride toothpaste on a clean, soft piece of cloth until a toothbrush seems more appropriate. Make sure that your child is also getting fluoride through the water supply. If not, be sure to ask your dentist or doctor about getting a fluoride supplement, since this will help the growth of good, healthy teeth.
Q: If a baby tooth is missing where the cleft goes through the dental arch, does that mean that a permanent tooth will also be missing?
A: No. There may or may not be missing permanent teeth. We do not recommend early x-ray studies of the dental arch, since there is nothing to be done, usually, until the permanent teeth erupt. If a permanent tooth or teeth are missing, the space may be closed up, or left open for a false tooth or dental bridge. This depends on many considerations that your orthodontist will discuss when full orthodontic treatment begins.
Q: If the baby teeth are crooked, does that mean that the permanent teeth will come in crooked?
A: No. The position of the baby teeth does not indicate anything definite about the permanent teeth. Sometimes, the permanent teeth come in much straighter than the baby teeth. However, most children with repaired cleft lip and palate conditions will need orthodontic care when the permanent upper teeth have fully erupted.
Q: If a baby tooth erupts in the palate in the area of the cleft, rather than in the dental arch, does it need to be pulled out?
A: No. Most of the time, a palatally-positioned tooth does not bother a child. If it is pulled out, a hole (fistula) can be created from the mouth in the nose. When the tooth loosens and comes out on its own a fistula does not usually develop. A permanent tooth in the palate may need to be extracted, however.
Q: If the upper front teeth are rotated or unattractive, at what age can they be corrected orthodontically?
A: The upper front teeth can be straightened at almost any age, although there are many considerations. As a general rule, it is best to avoid extended periods of treatment that use up the patient's cooperation. In some cases, where a child is very self-conscious about the appearance of the upper front teeth, some limited orthodontic treatment to improve the position of these teeth is recommended. In most children, however, treatment is delayed until full orthodontics is started around age 11 or 12 years.
Q: At what age should a cross-bite be corrected?
A: A cross-bite, where some upper teeth are positioned inside of the lower teeth, usually does not cause a biting or chewing problem. In spite of this, some orthodontists correct cross-bites early on, such as age 4 years on up. Some severe cross-bites may need early correction, although most cross-bites can be corrected when other orthodontic work is in progress. It is not unusual for orthodontists to vary widely on opinions as to when to correct cross-bites. There are many considerations involved, but early treatment is not usually necessary.