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Cleft Lip And Palate : Orthodontic Management

Introduction

Cleft lip and palate (CLP) is the most common congenital abnormality to affect the face worldwide. It was reported that in Malaysia, 1 in 700 births is a cleft baby3.

Who Are The Specialists?

A child born with CLP will require complex long term treatment from the birth and continue up to the age of at least 20 years, depends on the severity of the case. The management of a CLP patient involves many specialists who treat different conditions caused by the cleft1,2,3,4,6.

Members of A Cleft Team

Cleft Surgeons (Plastic/ Oral/ Maxillofacial/ Craniofacial Surgeon) Orthodontist Speech therapist ENT Surgeon Paediatrician Paedodontist Prosthodontist Psychologist Audiologist Geneticist Dentists Nutritionist Social Worker

Treatment For CLP

An example of a health care pathway for the management of CLP3:

  • Birth: Counselling, feeding advise, pre-surgical orthopaedics
  • 1 – 3 months: Lip repair
  • 9 – 12 months: Palate repair
  • 1 – 2 years: Hearing assessment
  • 3 – 4 years: Speech assessment
  • 3 – 7 years: Deciduous dentition: preventive dental advise
  • 8 – 10 years: Mixed dentition: orthodontic assessment
  • 9 – 12 years: Mixed dentition: alveolar bone grafting (ABG) with/without expansion
  • 13 – 17 years: Permanent dentition: definitive orthodontic treatment
  • 18 years and above: Jaw surgery and plastic surgery (if needed)

How does CLP Affect The Teeth?

A cleft of the lip, gum (alveolus), and/or bone of the jaw can produce a variety of dental problems. The commonly seen dental problems include1,2,4:

  • Front teeth coming into the mouth twisted and/or in the wrong position
  • Teeth poorly formed with abnormal shaped crown and/or root
  • Missing or extra teeth
  • Small or peg shape teeth
  • Delayed tooth eruption
  • Abnormal tooth alignment
  • Upper jaw and arch of the teeth become narrow in a repaired cleft palate
  • Anterior and/or posterior crossbites

Dental Care During The Deciduous Dentition

Early visit to the dentist is encouraged. Many dentists recommend that the first dental visit at about one year of age or even earlier if there are special dental problems4. As the primary teeth erupt, preventative dentistry is established. Oral hygiene instruction and dietary advice is provided. If necessary, the use of fluoride supplementation is instituted. Good oral care is particularly important as many CLP children have some poorly formed teeth. Therefore, the rest of the teeth must be kept in very good condition as future treatment may be needed to straighten them. Orthodontic treatment is rarely indicated in the deciduous dentition.

Dental Care During The Mixed Dentition

Mixed dentition begins when the first permanent teeth erupts at around 6 years old. A full orthodontics assessment is important at this stage.

At around 8 – 10 years old, Alveolar Bone Grafting (ABG) may be necessary for some CLP child if the original cleft creates a gap at the jaw bone. This gap can prevent the permanent teeth from coming through in the correct way. The role of ABG is to repair the gap in the bone, provide bone as a base to ensure that the new teeth have a stable support to erupt. The fragments of bone are usually taken from the hip or the legs. This procedure is normally carried out before the eruption of the permanent upper canine.

Commonly, orthodontic treatment is needed before ABG to expand the narrow upper arch, and create better surgical access for the surgeon so the maximum amount of bone can be placed. This expansion is often achieved with fixed orthodontic appliances or removable appliance. The most commonly used fixed orthodontic appliance is a quadhelix. This phase of treatment may takes about 6 – 12 months1,6. The orthodontist, oral surgeon or plastic surgeon will determine the timing to carry out the ABG.

Quad Helix Appliance

Dental Care During The Permanent Dentition

Once all the permanent teeth have erupted (age 13+), definitive/final orthodontic treatment can be undertaken. Treatment from this point may be2:

Prosthodontic work involves in replacing the missing tooth/teeth by using dentures, bridges or implants.

Orthodontic treatment only Fixed appliances (braces) is usually indicated to straighten the teeth alignment and where possible, to close all residual spaces without the use of dentures, bridges or implants.
Orthodontic treatment finishing with prosthodontic work Prosthodontic work involves in replacing the missing tooth/teeth by using dentures, bridges or implants.
Orthodontic treatment with orthognathic surgery In cases with severe skeletal deformity, bone cut is necessary to correct the misalignment of the dental arches. This surgery is referred to as orthognathic surgery. The procedure may involves moving forward of the upper jaw with/without moving the mandible jaw. Orthognathic surgery may be carried out when a CLP individual is near the completion of growth, usually at 18 years old.
Orthodontic treatment, orthognathic surgery and prosthodontic work  

Benefits For Treatment

The benefits for orthodontic treatment are1,6:

  • Improve teeth function, especially in eating
  • Improve appearance
  • Make the teeth easier to clean
  • Improve in self esteem

Further Help and Advice

  1. Talk to the child’s doctor or health care provider.
  2. Contact CLAPAM – Cleft Lip and Palate Association of Malaysia is a support organisation consisting of parents with children born with cleft lip and/ or palate, adults with cleft lip and/ or palate and healthcare professionals who manage such individuals. Box # 611, Lot 4.46A, 4th Floor, Wisma Central, Jalan Ampang, 50450 Kuala Lumpur. Tel/fax: 03-21621445. Email: senyum@clapam.org.my / clapam@streamyx.com. Web: http://www.clapam.org.my/

References

  1. Cleft Lip and Palate Association (2015). Services: Publications and Information Leaflets. Retrieved March 19, 2015 from http://www.clapa.com/services/pdf_downloads/
  2. Cleft Lip and Palate Association of Ireland (2015). Publications: Information Leaflets. Retrieved March 19, 2015 from http://www.cleft.ie/publications/information-leaflets/
  3. Cleft Lip and Palate Associationof Malaysia (CLAPAM) (2015). Introduction. Retrieved March 19, 2015 from http://english.clapam.org.my/index.php/extensions/introcleft.
  4. Cleft Palate Foundation (2015). Dental Care for Child with Cleft Lip and Palate. Retrieved March 19, 2015 from http://www.cleftline.org/parents-individuals/publications/dental-care-for-a-child-with-cleft-lip-and-palate/
  5. Cobourne, M.T. & DiBiase A.T. (2010). Handbook of Orthodontics. Philadelphia: Mosby Elsevier.
  6. Devlin, H.B. (2003). The Treatment of Cleft Lip & Palate, A Parent’s Guide. London. The Royal College of Surgeons of England.
  7. Prakash, A. (2013). Image of Quadhelix. Retrieved March 20, 2015 from http://orthocj.com/2013/05/post-expansion-methods-of-retention/
Last Reviewed : 16 February 2016
Writer : Dr. Then Poh Kiun
Accreditor : Dr. Rafeaah bt. Ayat Khan