Orthodontic Treatment
Because cleft palate affects the form and growth of the upper jaw, the teeth becoem a special consideration. Development and alignment of the teeth and their relationship to the jaw needs to be addressed during infancy and throughout the child’s growing years.
Infancy.
Before initially closing the infant’s lip, the use of a presurgical prosthesis called a palatal appliance is helpful in positioning the maxillary segments and narrowing the gap between them. This also helps to establish a normal alveolar arch which is essential for future dental occlusion.
Acrylic Palatal Appliance
In children with bilateral clefts, the appliance helps to keep the maxillary segments in proper alignment. At the time of primary cleft lip repair, it is helpful to have a more normally shaped alveolar arch which aids in better construction of the lip and nose.
Controlling the segments of the upper jaw and palate with the use of a prosthesis is important in the growth and development of both the facial skeleton and dental arch. A prosthesis also facilitiates proper occularion of the permanent teeth. Occlusion refers tot he way the upper and lower teeth come together. One of th requirements for normal occlusion is a proper relationship between the upper and lower jaws.
Once it has been determined that your baby needs a prosthesis, you will be referred to an orthodontist who is a member of the cleft palate team. The first step is for tht eorthodontist to make an impression or model of the baby’s mouth by using soft clay-like material. This is used to fashion the acrylic appliance. It has an adjustment mechanism which allows for the expansion during growth of the upper jaw segments when necessary. The appliance should be removed daily, cleaned and reinserted into the child’s mouth. It is held in place with denture adhesive cream. Infants adapt tot he appliance very easily and quickly. The device also aids in feeding and is helpful in the child’s overall facial development.
Your child will wear the prosthesis unil the cleft palate is surgically repaired. repair of the cleft palate is accomplished in one single surgical procedure performed between six to eighteen months of age.
Ages Five to Eight years.
As the child grows, the bony arch that supports the teeth, the aveolus, may become too narrow or incorrectly shaped. This condition is called callapse of the alveolar arch and requires orthodontic treatment. A prosthesis called an expansion device is inserted in the mouth which gradually expands the arch. Once the arch is expanded, its shape is maintained as the child grows and develops either with continued use of the expansion device or with a different type of prosthesis which is temporarily inserted into the mouth.
A. An expasion device.
B. Arch expanded to normal limits.
As the permanent cuspid (canine or eye) teeth develop and begin the process of eruption, usually between seven to nine years of age, it is necessary to correct the bony defect in the alveolar ridge. The surgical procedure used is a bone graft. It involves filling the space betweent he edges of the alveolus with a small amount of bone taken surgically from the hip.
Braces placed on teeth. Note the cleft in the bone of the upper jaw.
Correcting the defect in the alveolar ridge is delayed until the permanent canine tooth is partially formed. As the tooth erupts, it stimulates the growth of the transplatned bone and thereby completely closes the cleft present in the gum region.
To prepare the area for bone grafting, the orthodontist applies orthodontic bands and wires (braces) to the teeth; he or she will work with your child until the teeth are properly positioned.
After surgery, a splint is applied to stabilize the dental arch and is worn for about three months. During this time, it is important for your child to have a soft, pureed diet. the surgical team will give you specific diet instructions.
At the end of the three month period, the splint is removed and an orthodontic retainer is used to maintain the position of the alveolar ridge. It is worn for about six months.
Ages Eight to Twelve Years.
Ages eight to twelve are called the period of mixed dentition because children lose their primary (baby) teeth, and their secondary (permanent teeth erupt. Standard orthodontic treatment with bands and wires (braces) is used to move the teeth into a more normal position. This enables the orthodontist to create a normal arch form and a good positioning of hte upper and lower teeth.
If there is underdevelopment of the upper jaw, over development of the lower jaw or a combination of the two, further recommendations for treatment will be made. In about ten percent of all cases, surgical treatment may be necessary to correct skeletal deformities of the upper and/ or lower jaws. Treatment is delayed until orthodontic alignment of the teeth is completed, and this surgery is performed no earlier than fourteen to sixteen years of age.
Upper jaw surgery involves incisions in the soft tissues inside the mouth which cover the maxilla, allowing the surgeon to advance or move it forward. The new position of the bone is then secured with miniplate fixation. While this type of surgery is not frequently required, it can enhance the function and appearance of the teeth and jaws while improving speech and nasal breathing.
Surgery on the lower jaw may be necessary to correct the skeletal deformity. it is performed which the jaw appears to be overgrown and must be sent back to balance both the upper and lower jaws. This setback procedure is called a mandibular osteotomy.
Final Orthodontic Treatment
Final orthodontic treatment focuses on the proper positioning of the teeth in the upper and lower jaws. Absent teeth are corrected witha bridge, a removable partial denture or the newer technique of dental implants. Depending on the particular cleft deformity and your child’s unique problems, any one, or a combination of these techniques, may be recommended.
A. Secondary Lip, Nose and Skeletal Deformity following bilateral cleft lip/ palate repair performed outside of our institution.
B. Final result following correction of the lip, nose and skeletal surgery combined with prosthetic restoration.
C. Profile of the same patient prior to surgery. Note the protrusion of the mandible and retroposition of the entire midface.
D. The same patient following lip, nose and skeletal surgery. Note the excellent proportions in the profile.
E. Malocculsion and Progenia following primary surgery.
F. Occlusion after skeletal surgery and prosthetic restoration.
