What about the Teeth?

You may or may not know that teeth are important in infants and young children for the proper chewing of food, the spacing for 'adult' teeth later in life and for some sounds when the child is learning to speak.  Therefore it is really important to protect and care for the baby teeth for as long as possible in a cleft affected child. 

When the palate is affected there is a high chance that the teeth will also be affected. This is mostly in clefts that affect the gum ridge, but with a palate affected and due to the pulling and stretching of the gum during repair, the path that 'normal' teeth would take to erupt to the surface has to be compromised in a cleft affected child - doesn't it? That stands to reason for me.

As well as that, the teeth that are in the 'gap' of the cleft are most likely to be missing also.  I was always of the belief they were Tim's 'Vampyre' teeth that weren't there, but when I researched this I discovered that it's often the lateral incisors (next to our two front teeth) that were missing usually.  In a unilateral cleft the child may only be missing the one tooth, but in a bilateral cleft both are usually missing.

As always though, every child is unique and every child is different, and so you will need to consult with your dental team regarding your own situation.  Some children have missing teeth, some have more teeth than expected, some have the right amount but in the wrong spots.  Your child will be well cared for by the Orthodontist and the general Dental Department they are seen through during their treatment timeline. 

Who will be involved in dealing with the missing teeth?
Several dental specialists will be most important in planning treatment. Orthodontists align improperly placed teeth, while prosthodontists can replace missing teeth in a variety of ways. Oral and maxillofacial surgeons perform surgery to the teeth, mouth, and surrounding areas of the head and face. Coordinated planning by all specialists involved is necessary for the best result. You child may need all or just some of these listed specialists, just ask.

What role does the orthodontist play in replacing a missing tooth?
The large majority of patients with clefts will require full orthodontic treatment, especially if the cleft has passed through the tooth-bearing ridge. Goals of treatment will be to line up the teeth in the upper arch, create an arch form that is harmonious with the lower dental arch, and line up the midline of the upper arch with that of the lower arch. When a tooth is missing, the upper midline is usually shifted, so this must be corrected. A space is often opened up and maintained for later replacement of the missing lateral incisor.

If the thought of having to pay for braces has you worried beyond belief, read the What about costs page and then come back.

Tim had braces to help line up the gum ridge prior to his bone graft operation in 2005.  This operation is designed to take bone from the 'hip' area of a child for use in the gum ridge.  The surgeon pulps the bone and then tucks it into a pocket that is made in the gum, and then that is closed over with sutures.  After a while, the bone grows and helps to 'bridge' the gap that was formed by the cleft.  Apart from closing the gap this graft then provides a surface for a tooth to naturally grown down through, or a prosthetic tooth can be attached into the new ridgeline.  Prosthetic teeth, known as titanium teeth here in Australia, are not covered by the Medicare system, so start saving!

Is the missing tooth always replaced?
I have read in other articles that in some instances, the space for the lateral incisor will be orthodontically and/or surgically closed by moving the canine forward into the space normally occupied by the lateral incisor. This will then require modification of the canine to make it appear as a lateral incisor. This may be accomplished by adding plastic or porcelain filling material or a porcelain crown to reshape its appearance. I don't know if this is a common practice in Adelaide, but you can always ask if you're interested.  

Does my child only see an Orthodontist?

No, they also see the Dental Clinic for regular check ups and procedures as needed.  Often the Dental staff would have conferred with the Orthodontist, but you do see them for run of the mill kinds of things such as regular check ups to be sure all the teeth are being brushed properly.  With cleft affected kids this can be rather tricky as teeth form in all odd places and it's hard for the little ones to keep track of where they are hiding in their mouth! 

We nicknamed Tim the Shark as he has several 'rows' of teeth in his palate from where teeth erupted nearer the midline following the palate repair and then the hip bone repair.  Tim has seen Dr Sam Gue, a funky and very personable Dentist who runs the Dental department at the WCH here in Adelaide. 

Unfortunately, we are Public patients so we don't always get Dr Gue, but the Dentists we do see are very good too.  It's the lack of communication that's the biggest concern and having the one dentist seeing your kid all the way through would be so good .. if only!

Recently xrays showed that Tim required some 'procedures'.  I wasn't actually told what the 'procedure' was until the day we turned up and they popped the little gas mask on him... he was having teeth extracted.  Yes, you read right. Not 'Tooth' but "Teeth" - 2 to be precise. And all that only one day before we headed off for a three day camping trip!  Sometimes you wish the department would just 'consider' you a little more in their timing, but beggers and all that!

In true Tim fashion he bounced back with nary a flinch, and the camping trip had no hiccups (teeth related, that is - it had plenty of other 'adventures'.. but that's a whole other story!).  He now has both of the teeth in a little jar.  The teeth were actually very good on the surface but the problem lay within the gum line and the teeth were not properly formed.  This is a common problem with cleft-affected children, apparently. Speak to your Dentist if you are concerned.

In xrays we can also see Tim has teeth lying horizontal in his gum so no doubt there will be procedures for those to come as well - further down the track.

So, what else?

The rest of the information below was located on a site that may or may not reflect the practices in Adelaide, however it doesn't hurt to know what's out there and that way you can always discuss the procedures with your team if you're interested to know more

What options are available for permanent replacement of the lateral incisor?
Treatment options for the permanent replacement of the lateral incisor depend upon whether or not the cleft has been repaired with a bone graft. In a non-grafted dental arch, there are two options for replacement:

  • First, a removable partial denture may be used to replace the missing tooth. While this option may be made to look acceptable, it has several disadvantages. The removable prosthesis must cover most of the palate for support. This may cause irritation on the roof of the mouth or at the gumline where it rests. Many patients also object to the extra bulk and removable nature of the partial denture and report that it feels unnatural. This type of prosthesis is best as a temporary replacement as described above.
  • The second option in a patient without a bone graft is a fixed bridge. The missing tooth is restored with an artificial one connected to crowns (caps) on teeth on each side of the cleft. Because there is loss of supporting bone at each tooth on either side of the cleft, two teeth on each side must usually be crowned to give adequate support to the bridge. This type of prosthesis is not removable. Its contours and appearance look and feel more natural than a removable partial denture. However, it does require grinding down the support teeth in order to crown them and connect them to the artificial tooth. Cleaning between the crowned teeth also becomes more difficult since they are connected.

Can a fixed bridge be made immediately after braces?
In a teenager or young adult, the nerves and blood vessels in the tooth pulps are rather large. Drilling down these teeth for crowns may expose the pulps and require root canal therapy. Therefore, this type of treatment must usually wait until adulthood when the pulps are smaller.

What options are available for a patient who has had a bone graft?
Bone grafting the cleft site in the upper jaw creates a more normal arch and eliminates special restorative considerations relative to the cleft. A conventional fixed bridge as described above may be used. In many cases, only one tooth on either side of the cleft needs to be crowned, since the graft has stabilized the arch and added bone. If the teeth that hold the bridge are not otherwise in need of restoration, a resin-bonded fixed bridge may be chosen. This type of bridge requires much less tooth reduction of adjacent teeth, and there is no danger of nerve involvement. A porcelain replacement tooth is held in place by metal extensions cemented to the backs of the adjacent teeth. This is a more conservative restoration with regards to tooth preparation but still requires connecting teeth together.

The most natural, lifelike restoration for a patient with a bone graft is a single porcelain crown attached to an osseointegrated dental implant. This involves a surgical procedure where a titanium screw the size and shape of a tooth’s root is inserted into the bone at the site of the missing tooth. It is covered by the gum for six months while the bone bonds to the implant surface. Then the implant is uncovered and an artificial tooth (crown) is attached. While this procedure does require minor surgery, it does not require cutting down or crowning any other teeth. Cleaning is also easier because the replacement tooth is not connected to any other teeth. This restoration does give the most natural result but does require that sufficient bone is present in order to hold the screw.

In summary:

  • Finding the best treatment for a missing tooth requires cooperation and planning among several specialists and yourself.  Don't be afraid to ask questions.  it's unlikely they will avail you of information freely from my and other parent's experiences here in Adelaide.
  • A variety of options for successful tooth replacement are available
  • Patients with missing teeth and/or their parents should thoroughly discuss treatment options with the multidisciplinary team before making a decision.