Most of us have seen commercials of charitable organizations that provide primary cleft lip repair for individuals suffering from cleft lip and cleft palate. This surgery certainly is important, but it is only the first step on a long road to establishing optimized esthetics and function for these individuals. Dental specialists have unique skills and training to come alongside these children as a part of this journey. The dental specialists involved with cleft care are orthodontists, pediatric dentists, and oral and maxillofacial surgeons.
The first specialist the patient will encounter will be the pediatric dentist. They can help prepare the tissue for lip repair. They are also specially trained to understand the key stages in development and timing of future surgical procedures. Since any surgery can induce scarring, and this scarring can greatly hamper the growth of the midface, the goal of the team is to allow as much unrestricted growth while timing procedures to optimize dental, facial and skeletal development. The first time a cleft lip and cleft palate patient should see a pediatric dentist is no different than any young individual. We recommend the patient see a pediatric dentist within 3-6 months after their first baby tooth has erupted. The pediatric dentist will then closely monitor the development of the primary and permanent dentition. When permanent teeth, usually the canines or lateral incisors, start to erupt towards the defect in the bone of the upper jaw, a referral will then be made to the orthodontist and oral and maxillofacial surgeon.
The orthodontist and oral maxillofacial surgeon will then work closely together to properly re-establish form of the maxilla (upper jaw) and graft bony defects in the upper
jaw. The surgeon will also close any residual openings (oral nasal fistulas) between the nose and the oral cavity. Because the upper jaw is either in 2 or 3 separate pieces, the upper jaw usually has collapsed and is narrow. The orthodontist will expand the upper jaw and re-establish the normal shape and width (photo 1 and 2). The patient is then ready for the oral maxillofacial surgeon.
The surgeon will then proceed with grafting the bony defects of the maxilla and unifying it into 1 single jaw (Photo 3 and 4). This is done with either bone from the anterior hip (iliac crest) or from genetically produced proteins (rhBPM) which will stimulate spontaneous bone formation. Once healed, the teeth can then be aligned orthodontically. This treatment usually occurs between 7 to 11 years of age. The range is due to individual growth variation.
The individual’s growth is then closely monitored. If there are signs of restricted growth of the upper face, the surgeon and orthodontist may, around 10 yrs of age, place temporary bone anchorage devices along with orthodontic elastics to help promote improved growth of the middle face (maxilla) to help minimize or prevent future surgeries. If the facial growth is adequate, the orthodontist will complete final alignment of the teeth as any normal individual. If the face shows restricted growth, treatment will start when overall skeletal growth is nearly complete. The orthodontist and oral maxillofacial surgeon work closely to properly align the teeth and bring the facial bones into proper alignment. This is done by either surgical repositioning of the jaws (Orthognathic Surgery) or using surgical distraction where the midface is slowly moved to the correct position. Distraction allows the bones to be moved much farther
distances than with a single procedure. This final treatment optimizes the cleft patient’s speech, function, airway and facial appearance.
None of the dental specialists work in isolation. They are an integral part of a skilled team of otolaryngologists, plastic surgeons, speech therapists, social workers, hearing specialists, plus others. These individuals work in coordination to help optimize the other members’ treatment goals. The cleft lip and cleft palate team associated with Children’s Hospital here in Colorado Springs has a team of dedicated and caring people that provide quality, compassionate care as an independently,fully accredited cleft lip and cleft palate team.
If you have any further questions concerning care provided by the cleft lip and cleft palate team, please do not hesitate to contact Children’s Hospital of Colorado Springs or Dr Thoman.