Children with cleft lip and palate present with
many needs, including oral and dental problems. This article will focus on oral
issues and relevant treatment modalities.
A Team Approach is Required The cleft lip and palate team must work together for the benefit of the young patient. The team usually consists of the following members: the pediatrician, plastic surgeon, oral & maxillofacial surgeon, dentist, orthodontist, ENT physician, psychiatrist, psychologist, prosthodontist, speech therapist, audiologist, and coordinator.
A Partial List of Oral Problems
in Children with Cleft Lip & Palate •Feeding Problems
•Missing teeth- 50%
•Supernumerary Teeth- 20%
•Dystrophic (hypoplastic) teeth- 30%
•Disturbances of tooth eruption
•Ectopic tooth eruption
•Malocclusion- 100%
•Dental caries and gingivitis
Feeding Problems •Infants that have a cleft palate may have some difficulty in feeding.
•The use of a medicine dropper, spoon or special feeder (e.g., a large, soft nipple, known as a lamb's nipple or a cleft palate nipple) may simplify feeding.
•Breast-feeding reduces the risk of ear infection.
•If the palatal defect is wide and complete, a removable obturator may be required to close the defect and prevent regurgitation of the food into the nasal cavity.
Missing Teeth (Hypodontia) •Missing teeth- 50%
•Abnormalities in dental development can be related to initial disturbance and disruption of the embryonic process of dental lamina formation.
•Notably in the area of failed merging and fusion of the medial nasal, lateral nasal, and maxillary processes (Bøhn, 1950, 1963; Ross and Johnston, 1972; Ranta, 1986; Long, 1998).
•The absence of the lateral incisor appears to be in the range of 10% to 20% in the primary dentition, and 30% to 50% in the permanent dentition. (Bøhn, 1950, 1963; Jordan et al., 1966; Ranta, 1972, 1986, 1990; Ross and Johnston, 1972; Suzuki et al., 1992).
•In complete clefts, the deciduous and permanent lateral incisors are generally absent, ectopic, diminutive or represented by two small conical teeth in each cleft margin.
Extra Teeth •Supernumerary Teeth- 20%
Dystrophic Teeth •Poorly shaped teeth- 30%
Ectopic Eruption •Disturbances of tooth eruption.
Bad Bite •Malocclusion- 100%
Dental Caries Disease •Significantly higher rate of dental caries
•The regular administration of sucrose-containing medicines will give rise to dental caries.
•It is essential to explore the possibility of a sugar-free alternative in these cases.
Surgical Timetable •For lip closure: 90% of cleft teams in the world close the lip between 3 and 6 months of age.
•Age 9-12 months - Repair of cleft palate.
•Age 7-9 years - Alveolar bone graft
•Other surgical procedures can be performed in patients with severe clefts as necessary.
•Evidence-based treatment in the strict sense of the word is not being adopted in the early treatment of cleft patients.
A Protocol for Treating Clefts •Infancy phase – optional dentofacial orthopedics
•Surgical repair of lip & palate
•Initiate Infant Oral Health Program
•Phase I orthodontics - mixed dentition
•Differential expansion & alignment
•Surgical bone graft in area of lateral incisor(s)
•Phase II orthodontics - permanent dentition
•Full mechanotherapy to align dentition
•Orthognathic surgery + phase III orthodontics
•Integrated with growth completion
•Prosthetic & esthetic reconstruction – young adults
Oral and Dental Care: Birth to 6 Months •Surgical repair of cleft lip between 3 and 6 months.
•Initiation of the Infant Oral Health Program.
Optional Appliance Treatment for Infants •No Treatment
•Passive Appliance
•Premaxilla Active Appliance
•Grayson’s Molding Appliance
The Passive Palatal
Appliance •Used when anterior cleft width is narrow, and lip can be repaired without significant tension on surgical site.
•Removable.
•Maintains posterior arch width while allowing lip to close cleft.
•The appliance is inserted prior to surgical lip closure. Proper seating can be verified by blanching of tissue seen through the clear acrylic shell.
•The appliance is not removed at all during the first post-surgical week. It is worn continuously for the next few months, being removed only for cleaning.
•In two months, will need to have the anterior acrylic removed – to make room for the moving premaxilla.
The Passive Palatal Appliance - Bilateral Cleft Example •Maintains the lateral width of the maxillary segments after lip closure.
•If this width is not maintained, the lateral segments usually move medially, in response to the force of the newly-closed lip.
•Problem: need to modify the appliance as the child grows.
•Dramatic changes can be seen four months later, accomplished by maintenance of the arch width by appliance.
•The premaxillary segment is now re-oriented in response to pressure from the newly-established band of the continuous lip.
•The anterior portions of the lateral maxillary segments will eventually need to be freed of their acrylic cover – to allow for further molding.
The Passive Palatal Appliance - Unilateral Cleft Example •Maintains the lateral width of the maxillary segments after lip closure.
Compound Dental Impressions •Adequate suction should be available as a safety precaution.
•Easiest to use the gray impression compound. Low melting point.
•Place the bulk in the center.
•The infant is seated, held from behind, and leaned 45º forward, head elevated.
•The impression is taken.
Alginate Dental Impressions •Tiny, perforated trays are best.
•The tray is rimmed completely with a utility wax bead – forming a posterior dam.
•The impression must: completely include the lateral maxillary segments, reproduce the mucobuccal fold, and provide adequate extension of the impression into the cleft area.
•The impression must: extend into the nasal chambers and every available undercut. These undercuts provide the retention for the appliance.
•Towards the end of impression procedure, the nasal passage exposed by the cleft is blocked by the impression
material, therefore, the child may become slightly cyanotic after 20 seconds.
•Withdraw the impression and check to make sure that no portion of the impression has been torn away.
•Next, check the cleft areas for any retained impression material.
•Note: this procedure is best done in the operating room environment. Consider pre-oxygenating infant before the impression is taken.
•Adequate suction should be available as a safety precaution.
Safety Tip for Taking Alginate Impressions •Cottonoid patties are routinely used in neurosurgery. They are made of synthetic fibers with a long tail of suture material extending from them.
•Cottonoid patties can be trimmed to fit, and inserted into the maxillary cleft(s) with the tails brought out of the mouth.
•The infant is seated, supported from behind, and leaned 45º forward, head elevated.
•The impression is taken.
•This technique prevents problems such as getting alginate caught in the nose or airway.
Materials Needed for Making the Palatal Plate •Use a good separating medium on the dental cast, and apply it with cotton swabs or small brush.
•Self-cure clear acrylic powder and liquid is placed.
•The appliance is trimmed so that the vomer is free in the anterior third, to make room for the bending response to the pressure of the newly-closed lip.
The Premaxilla Active Appliance •A segment of elastic orthodontic chain with a
•1.0 cm2 x 3.0 mm thick section of resilient denture liner is attached to the resin plate via the buttons.
•The section with the resilient liner is positioned over the prolabium.
•Treatment continues until the plastic and reconstructive surgeon determines that the premaxilla has been moved to a favorable position for cleft lip repair—usually 2 to 3 months.
•A palatal expansion device may be incorporated into the plate if the palatal segment is too collapsed to allow adequate retraction of the
premaxilla.
•Note: it is usually more practical to use a special elastic tape for this purpose - changed every day by the parents.
Grayson's Molding Appliance •Surgical correction of a unilateral or bilateral cleft lip may result in a flattened alar cartilage.
•This may require corrective surgery at a later date.
•To avoid the problem with the flattened alar cartilage, Grayson has described the presurgical nasal orthopedic molding appliance.
•It molds the palate, alveolus and nose.
•Advantage: excellent early results
•Disadvantage: no long term results; controversial, and complex.
Dental Care: 6 Months - 3 Years •Age 9-14 months - surgical repair of cleft palate.
•Continue to teach parents about a healthy diet, infant oral hygiene, dental development, and future treatment needs.
•Continue the Infant Oral Health Program - with a 6 month recall.
The Infant Clinical Exam •The easiest way to examine a baby is with its head gently lowered onto the dentist’s lap and the parent sitting facing the dentist.
Oral Hygiene Instructions •Parents should be shown how to lift the repaired lip, stretching the lip carefully by sliding an index finger along the labial gingiva.
•An interspace brush is especially helpful for teeth in the cleft region of the hard palate. Easy to make!
•Parents should be given the opportunity to practice the toothbrushing technique in the dental office.
•The parents need extra support, encouragement, and praise - to persevere.
Dental Care: 4-7 Years •Orthodontic dental records.
•X-rays, especially maxillary occlusal radiographs.
•Photos.
•Phase I orthodontics around age 7-9.
•Provide appropriate preventive and restorative care.
Behavior Management •Get to know the patient as an individual and to allow time for acclimatization and confidence building.
•In some cases the young patient with a repaired cleft may be shy, nervous, or have a behavioral problem.
•Problems with speech and hearing may also present a possible barrier to satisfactory communication with the child.
•Consider using nitrous oxide.
Extractions •Early removal of primary teeth in children with a cleft is often contraindicated because of possible space loss, making orthodontic treatment more difficult.
•An intact dentition will allow for the best possible results from later orthodontic intervention.
Restorative Care •Pulp treatment procedures and stainless steel crowns for primary molars should be used where appropriate.
Dental Care: 7-9 Years. Preparation for the Alveolar Bone Graft •Removal of primary teeth in surgical field to permit healing and primary closure of graft site
•Arch Expansion
•Stent fabrication
•Gingival health – reduce inflammation in surgical site
Bone Grafting: Age 7-9 Years •The premaxilla needs to be properly aligned with the lateral palatal segments prior to alveolar bone grafting.
•Alveolar bone grafting may be performed between 7 and 9 years of age.
•Grafting only restores the alveolar process, however; no graft is placed in the palate and bone does not form there.
•A lateral incisor as well as a cuspid may erupt through the area of new bone formation.
Dental Care: Age 7-9 Years. Oral Hygiene Instructions •Cleaning of any anterior teeth positioned high in the labial sulcus should be given special attention.
•The child is shown how to lift the upper lip out of the way to facilitate brushing.
•Fissure sealants should be provided as soon as the teeth have erupted sufficiently.
Other Dental Care: Age 10 + Years •Dental records to monitor jaw growth, dental development and bone graft.
•Braces for dental alignment as needed.
•Prosthetic replacement of missing teeth as needed.
•Monitor dental hygiene; provide appropriate preventive and restorative care.
Other Dental Care: Age 10 + Years Top: patient received expansion with a hyrax appliance, alignment of incisors, and alveolar bone grafting.
Bottom: a removable orthodontic retainer with plastic teeth.
Prosthodontic Treatment •Tooth recontouring
•Enamoplasty
•Composite bonding
•Crowns
•Laminates
•Make canine/premolar look like lateral incisor/canine
•Correct crowding/spacing
•Where space closure (in the lateral incisor cleft area) is not possible, the use of adhesive bridgework has been advocated.
•A resin-bonded (Maryland) bridge involves little preparation of the teeth, and doesn’t interfere with tooth eruption or growth.
Implants in Mature Adolescents •Implants: Method Simulates Natural Tooth Replacement
•Maintains alveolar bone graft
Early V. Late Implants •Debate about timing of implant placement
•Use typically limited to mature jaw
•Passive eruption is completed
•Early placement: advantages/disadvantages
•Maintains graft
•Permits a more stable oral repair earlier
•Eliminates need for transitional prosthesis
•But: relative submersion due to adjacent passive eruption
Implants and Passive Eruption of Adjacent Dentition •This illustration demonstrates the passive eruption of the teeth adjacent to the implant and the gradual submersion of the implant over time.
•In order to restore the implant on the right, bone must be removed to access the collar for crown placement.
•Lack of long term studies demonstrating the efficacy and safety of implants in the preadolescent and early adolescent period.
•Recommend implant placement only after growth maturity in both arches. (Brecht, Fantuzzo, Fan, Guckes and Roberts)
Children with cleft lip and palate present with
many needs, including oral and dental problems. This article will focus on oral
issues and relevant treatment modalities.
A Team Approach is Required
A Partial List of Oral Problems
in Children with Cleft Lip & Palate
Feeding Problems
Surgical Timetable
A Protocol for Treating Clefts
Oral and Dental Care: Birth to 6 Months
Oral Hygiene Instructions
Dental Care: 4-7 Years
