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This one is about: Show Us Your Pearly Whites! A Look at Orthodontia

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A Look at Orthodontia in Children with Clefts

by Christine Schnatterer

When our children flash their wide smiles, they often fall short of the "Colgate Smile". Teeth are important for aesthetic reasons and for supporting facial structures. Teeth are also essential for chewing food, and they play a major role in speech production.

The three stages of normal dentition, or tooth development, are:

1) The period of deciduous dentition, when the baby teeth are appearing.

2) The period of mixed dentition, when baby teeth are being shed and replaced with permanent teeth.

3) The period of adult dentition or permanent adult teeth.

The child with a cleft may require attention in all three stages. If the alveolar ridge (bone) was disturbed by the cleft, the teeth in the cleft line may be totally absent, or so late in erupting that proper natural alignment is impossible.

The need of orthodontic intervention to unlock impacted palatal segments and permit more normal growth has long been recognized. Some patients with cleft palates present a unique combination of both skeletal and dental abnormalities. Their dentition will require long periods of treatment (use of braces and/or appliances). The jaws may also be of major concern.

There are 5 reasons for orthodontic treatment on a continuing basis from childhood through adulthood:

1) to provide symmetry in the dental arch of the infant and bony support for the initial nasal repair;

2) to align the distorted and constricted palatal segments of the maxilla (upper jaw);

3) to maintain the gains made by expansion and dental alignment procedures;

4) to assist the eruption of permanent teeth; and

5) To support surgical positioning of the jaws when jaw surgery is necessary.

Clefts most often occur in the alveolar area between the maxillary central incisor (top front tooth) and the cuspid. The nasal deformity in a cleft patient is often related to the extent of the underlying bone deformity, and the width of the cleft is a major factor in subsequent tooth development.

It is not unusual for tooth development to be delayed in the child who is being treated for cleft lip and palate. Development of the second bicuspids can begin as late as six to eight years of age (three to five years beyond the normal period of the start of calcification). By examining such a child during mixed dentition stage, one might erroneously conclude that these teeth are congenitally missing. These children must therefore be examined periodically and treatment plans may have to be modified and often compromised, depending on the severity of the cleft, the growth of the jaws and the status of the developing deciduous and permanent teeth.

Dental anomalies occur frequently in persons with clefts. A common example, while not necessarily occurring in all cases, is the congenital absence of teeth, particularly those at the site of the cleft. Another interesting (albeit inexplicable) finding is the congenital absence of teeth that are not found along the cleft line. Since those teeth develop away from the site of the cleft, their absence, having been found to occur in greater frequency among the cleft population, becomes even more mystifying. One or all four bicuspids of some cases, may be absent. In addition, the second bicuspids of some cleft children may show an abnormal pattern of calcification and development.

It is also common for children born with clefts to have supernumerary (extra) teeth. These are sometimes seen in the non-cleft population, but not nearly as often. Supernumerary teeth are usually located next to the cleft site. Some emerge into the oral cavity, while others may remain unerupted within the maxilla. They may vary in size, shape and location. Some grow through the palate, while others grow between the gum and the lip.

Sometimes supernumerary teeth must be removed to facilitate the treatment of the remaining dentition. Whenever appropriate, however, they are maintained and used. For instance, if a lateral incisor is missing, a supernumerary tooth may be retained to take the place of the missing incisor. In some cases supernumerary teeth can be used to hold appliances used for expanding palatal segments.

Some of the teeth adjacent to the cleft may be rotated (twisted) when they erupt. Though in some those teeth may naturally rotate themselves into a more normal position after eruption, they may also remain severely rotated and need the help of an orthodontist to straighten them. In bilateral clefts both central incisors may be poorly developed and there may be insufficient supporting alveolar bone. This is especially true when the clefts are wide and the premaxilla is extremely mobile. Nevertheless, these teeth should be retained and rotated into a normal position after the clefts are grafted. Early rotation can damage the roots and jeopardize the longevity of the teeth. Naturally, we are anxious to see our children's teeth straightened as soon as possible, but timing is crucial and we must be patient.

Teeth that are not solidly anchored in bone can be lost in minor childhood accidents such as bumps or falls. This is usually nothing to be alarmed about, but the orthodontist or dentist should be notified promptly and his recommendations followed.

Also common in cleft children is the presence of ectopic (abnormally positioned) teeth. They may be placed in the palate and completely blocked out of the dental arch. Occasionally they may be transposed (switched in position with another tooth). Some decisions must be made about the disposition of these teeth as well.

Until recent years orthodontic therapy for the child with a cleft was not undertaken until after the eruption of all the deciduous (baby) teeth, or at approximately three years of age. Today many children are seen by orthodontists in their first year of life. In the early months the orthodontist may need to align the palatal segments before surgical repair of the lip or palate is attempted. There are several types of appliances that have been developed to reposition or push the premaxilla back and to expand and align the palatal segments prior to surgery. It is amazing what can be done today!

Since our children's teeth require so much attention, proper dental hygiene us of utmost importance. Starting with the first sight of and erupted tooth, the parent must clean the teeth with gauze or soft cloth after each feeding. When the child is old enough, he should be taught the importance of regular brushing. Proper techniques should be demonstrated and brushing should be encouraged and supervised. Remember that it is important to give
proper attention to ALL of your child's teeth - even those that are supernumerary, ectopic, rotated or poorly formed. Keep regular appointments with your dentist and your orthodontist and report anything that concerns you. Calcium supplements and fluoride treatments can and should be discussed with your dentist.

It is encouraging to know that through modern technology even the most discouraging configuration of teeth can be transformed into a beautiful smile. After the plan for orthodontic and prosthodontic correction is carried out, the smiles seen in high school portraits can be viewed as small miracles when compared with those in the early photos.

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