Cleft Palate/Special Needs Patients

Cleft lip and palate is the most common facial birth defect and occurs in 1/700 live births.  It is not primarily passed on in the genes but occurs randomly.  Problems such as exposure of the baby to alcohol or drugs or x-rays early in the pregnancy, or high temperatures from a hot tub or a fever have been implicated in this problem, to name a few.  The problem is usually identified before birth by an ultrasound in mid-gestation.  Usually those with clefts have missing teeth in the cleft area.  Sometimes there are extra teeth and undersized teeth. 

After some initial growth and weight gain, the baby has a surgical repair of the lip.  This is usually done at a couple of months of age.  When the child is about 18 months old, and before speech develops, the palate is surgically repaired.  All that appears is a scar, placed along the lip where the cupid's bow is present.  With palate closure, speech can develop normally.  Sometimes the palate repair is adequate and the child can adapt at other times, the soft tissues are inadequate and a hole develops in the palate called a "fistula".  The hole between the nose and the mouth makes it difficult to pronounce words without escape of air.  Some kids with cleft palates with fistulas or short palates will speak with a breathy tone to their voice called "hypernasality".  Their challenges in speech often require help by a speech therapist for many years as the doctors do their surgeries and change the mouth.

The palate usually narrows from the pressure of the cheeks and results in a crossbite.  Kids with cleft palate usually have little further treatment until they are about age 7-8 when the orthodontist steps in to expand the palate, allowing space for the eruption of the permanent teeth.  The timing of orthodontic treatment depends upon the severity of the defect, the stage of dental eruption and other factors.  We call this phase of orthodontic treatment "Phase 1A". This is the Palatal Expansion appliance that is typically used but other designs are used as well.

After the palate is expanded, special imaging study may be requested called a cone beam computer tomography scan.  It is done to make decisions about removal of any undersized or extra teeth.  Removal of these teeth may be done before the bone graft by an oral surgeon or at the time the bone graft is done by the plastic surgeon.  The bone graft is done to repair the palate and stabilize it.   The bone graft material sometimes comes from the child's own body, or is synthetic bone... kind of like "bone in a box", or a combination of the two.  After the bone graft material matures into solid bone, the teeth which are usually crooked can be aligned with partial upper braces.  Generally the bone graft is done first so that the tooth movement does not move the teeth out of the bone and into the cleft space.  But if it happens in the reverse it is unknown if there are any long term consequences to this.  It is prudent to do the bone graft before movement of the teeth adjacent to the cleft site.  This secondary stage of orthodontic treatment is called Phase 1B. 

A second phase of orthodontic treatment is done when nearly all of the permanent teeth erupt into the mouth.  This can be as early as age 10 in some girls to age 13  or 14 in boys with delayed eruption of the teeth.  After full orthodontic treatment is completed, the patient's braces are removed and retainers are placed.  Usually the retainer has a false tooth on it called a "pontic."  When growth is completed, the missing tooth is replaced by an implant which usually requires bone graft augmentation to make the ridge wide enough to accept the "implant fixture."  A crown is placed in the implant fixture a few months later once the bone matures around the implant.  For various reasons, some patients are not good candidates for implants and a bridge is recommended for them.  The orthodontic retainer will need to be remade once the implant is placed.  This is all that is needed by many cleft patients. 

Others have underlying growth problems in the upper jaw and the discrepancy between the jaws gets worse as growth completes.  These individuals may benefit from a surgical jaw correction called "distraction osteogenesis" in the mid-teen years to improve the appearance of the profile.  Others don't need this but will have jaw surgery once growth is completed in the early adult years.  In this case, braces are replaced in the late teen years in preparation for jaw surgery.  After jaw surgery, the final finishing of the case occurs with the braces and the implant or bridge is placed by the restorative dentist to replace any missing teeth.

Clefts are fixable and these individuals live a normal life, albeit with lots of medical and dental visits, to repair the cleft and associated dental problems.  Their orthodontic treatment involves 2-4 phases.  Sometimes slight "touch-ups" of the soft tissues are done in the adult years to fine tune the result.  These patients typically visit with a Craniofacial Team of experts who direct what should be done and when throughout their lives.  The challenge of their birth defect is one which typically matures both the patients and their parents faster than usual.  Some adapt well to their problems and others do not and require help from counselors.  We all need to be supportive of those born with clefts of the face and learn from them how to stay positive in the face of adversity.


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