Dental Care for Children With Cleft Lip and Palate

A cleft of the lip, gum (alveolus), 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 other cases, the incisor or other teeth may be present, but may be poorly formed with an abnormally shaped crown or root.

Finally, the teeth in the area of the cleft may be displaced, resulting in their erupting into abnormal positions. Occasionally, the central incisors on the cleft side may have some of the same problems as the lateral incisor.

A child with a cleft lip and/or 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 malpositioned, malformed or missing teeth, they require early evaluation by a dentist who is familiar with the needs of the child with a cleft.

With proper care, children born with a cleft lip or palate can have healthy teeth. This requires proper teeth 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 counseling can be provided by a pediatric or general dentist. Many dentists 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 dentist begins at about three years of age. The treatment recommended depends upon many factors. Some children require only preventative care while others will need dental fillings or removal of a tooth.

The first orthodontic evaluation may be scheduled even before the child has any teeth. The purpose of this visit is to assess facial growth -- particularly the growth of the jaws. Later, as teeth begin to erupt, the orthodontist will make plans for the child's short and long-term dental needs. For example, if a child's upper teeth do not fit together properly with the lower teeth, the orthodontist may suggest an early period of dental treatments to correct the relationship of the upper jaw to the lower jaw. It is not unusual for this initial period of treatment to be followed by a long rest period when the orthodontist monitors facial growth and dental development. With the eruption of the permanent teeth, the final phase of orthodontics completes alignment of the teeth.

Coordination of treatment between the surgeon and dental specialist is important since several procedures may be completed during the same anesthesia. Dental 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 management of the bony defect in the upper jaw that may result from the cleft. Reconstruction of the cleft defect may be accomplished with a bone graft performed by the surgeon. The orthodontist may place an appliance on the teeth of the upper jaw to prepare for the bone graft. A retainer is usually placed after the bone graft until full dental braces are applied.

When the child approaches adolescence, the orthodontist and the surgeon again coordinate their efforts if the teeth do not meet properly because the jaws are in abnormal positions. If the tooth relations cannot be made normal by orthodontics alone, a combined approach of orthodontics and surgical repositioning of the jaw is necessary. Such surgery is usually performed after the pubertal growth spurt is completed.

The maxillofacial prosthodontist is a dental specialist who makes artificial teeth and dental appliances to improve the appearance of individuals with cleft and to meet their functional requirements for eating and speaking. The prosthodontist may make a dental bridge to replace missing teeth. Oral appliances called "speech bulbs" or "palatal lifts" may help close the nose from the mouth so that speech will sound more normal. The prosthodontist must also coordinate treatment with the surgeon or the orthodontist to assure the best possible result. When a speech bulb or palatal lift is developed, the prosthodontist usually coordinates treatment with the speech pathologist. For the child or adult who wears one of these appliances, the care of the teeth holding the appliance is of particular importance.

Children with cleft lip or palate require the coordinated services of a number of specialists. For this reason, many parents seek care for their child at a cleft palate or craniofacial treatment center. At such a center evaluation, treatment planning and care are provided by an experienced, multidisciplinary team composed of representatives from a variety of dental, medical and other health care specialties. Even if you do not have such a center locally, the care your child will receive in such a center may be well worth the inconvenience of traveling to another city.

Parent and patient support groups are located throughout the country. You might want to join one to obtain support and practical help from others who share common problems. To obtain a list of cleft palate-craniofacial centers and parent or patient support groups in your region contact the Cleft Palate Foundation.

Anesthesia -- Drugs provided during a surgical or dental operation that put the child to sleep.

Bony Defect -- Area of missing bone, usually affecting the roof of the mouth in children with cleft palate.

Dental Extraction -- Dental procedures performed to remove damaged, malformed or malpositioned teeth.

Dental Restoration -- Dental procedures performed to repair or correct damaged, malformed or missing teeth.

Multidisciplinary Team -- A group of professionals who work together to help plan and carry out treatment for patients with cleft lip, cleft palate and related disorders. The group usually includes surgeons, dental specialists, speech pathologist and others who meet regularly to evaluate and discuss the patients under their care.

Oral Hygiene -- Care of the teeth and gums which is performed at home on a daily basis. This is performed first by the child's parent or guardian while the child is small, and eventually by the child under continued supervision of the parent or guardian.

Orthodontic Care -- Dental visits designed to move the teeth into better alignment with one another to improve chewing, oral hygiene and appearance.

Preventative Dental Care -- Regular dental exams during which teeth are checked for cavities and cleaned.

Pubertal Growth Spurt -- A period of rapid growth that normally occurs sometime between the ages of 10 and 16. The actual timing and length of this period of growth varies.

Restorative Dental Care -- Dental visits designed to correct dental problems.

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