Cleft lip & palate dental treatment

Children born with cleft lip and/or palate require additional and specialized dental care. Their care starts earlier than most children and generally has more components that non-cleft children. Cleft lip and/or palate is one of the most common birth differences seen. Approximately one in 700 children born will have a cleft of the lip and/or palate. The cleft can be limited to a small notch on the lip or be a complete separation of the lip and palate all the way from the front of the face to the back of the mouth. Ideally, every child with a cleft should be followed by a team of specialists who can schedule and coordinate care for the best outcomes.

Dental treatment for children with cleft lip and palate comes in phases.

  1. The Newborn: Newborn children can have their upper gums (jaw) and nose reshaped prior to the first surgery. The gap in the jaw can be reduced. The cartilage of the nose can be molded and the shaped changed for the first 2 to 3 months of life. After the fourth month, the shape of the nose cartilage will remain the same for the rest of the child’s life.  The first surgery for a cleft lip & palate child is usually done around age four months. The first dental care is a Nasal Alveolar Molding appliance or NAM. The NAM appliance can be used to reduce the gap in the gums, and reshape the cartilages of the nose. It can raise the tip of the nose on the effected side and reshape the flattened side (alar) cartilage. The first surgery closed the lip, but leaves a hole in the gums until the child is older.
  2. Pediatric Dentistry: Your child should see a pediatric dental specialist for routine care starting at age 6 months. Pediatric dental care will continue until the child is transitioned to a family dentist.
  3. Mixed Dentition Orthodontic Treatment:  When your child is 6 to 7 years of age they will be seen for the first orthodontic evaluation. Often the front tooth next to the cleft will be turned sideways. Also, the upper jaw will be narrow due to the scars from the initial cleft surgery. The orthodontist will coordinate the best timing for starting treatment. The first orthodontic treatment is usually between age 8 and 11 determined by when adult teeth are moving close to the hole in the gum. The orthodontic treatment is used to align the segments of the upper jaw and move the front teeth out of traumatic occlusion prior to the alveolar bone graft which closes the hole in the gums.
  4. Adolescent Orthodontic Treatment: At age 12 to 14 when the adult teeth are all erupted, they can be aligned with braces. Often there will be an underbite due to under-development of the upper jaw. This underbite will remain until the child’s face has completed growth in the late teens.
  5. Adult orthodontic Treatment: After the face has completed growth in the late teens, the underbite can be corrected. This requires braces and a surgery to move the upper jaw forward. The surgery is done in the middle of the braces as the surgeon will want to use the braces for the first couple months after the surgery.

Removing a wiggly baby tooth

Pediatric dentists say the best way to remove a wiggly baby tooth is to turn the tooth, like a radio knob instead of wiggling it.  The new adult tooth is suppose to push directly under the baby tooth, melting the root of the baby tooth until it is pushed out of the mouth. This process usually takes 2 to 3 weeks one the baby tooth starts to wiggle.

Adult teeth do not always read the instruction manual on how to grow. If you can see an adult tooth showing under the baby tooth or along side the baby tooth this can be a problem. The longer the baby tooth remains, it can misdirect the adult tooth out of line.

A baby tooth that is not loose with the adult tooth erupting along side or a baby tooth that is stubborn and will not come out needs to be seen by the dentist.


Extracted baby tooth

Removal of a back primary (baby) tooth due to cavities, gum infection or trauma can cause the neighboring adult teeth to shift to that side, and/or the underlying adult teeth to become blocked and impacted.

If one corner tooth (cuspid) is lost early, the front teeth can shift and tip to that side moving the center line of the teeth off center. Teeth moving into an available space takes about six months. If this starts to happen, the corner baby tooth on the other side can be removed and the front teeth will tip back upright and re-center to the jaw.

If a primary molar is removed early, the adult 6 year molar, just behind, can drift forward and block the unerupted bicuspid in front of the molar. A spacer or holding arch needs to be placed to protect the space for unerupted teeth.

Preventing problems from developing is always better than repairing complications from not planning ahead.

Serial Extraction

A child who’s new adult front teeth (incisors) are significantly crowded at age 7 or 8 has several options of how to address this problem. One of the most effective and least costly is serial extraction treatment.

The space for teeth in the lower jaw is fixed by age 5. After this time, the jaw will not increase in length in the area of the teeth. So, as the new teeth grow, if they are too large for the space they will overlap, rotate or grow in behind the primary (baby) teeth. If this is the case for your child, see your orthodontist for an evaluation and a plan of care. We call this size 32 teeth in a size 24 mouth.

If the crowding is great enough, and all the adult teeth are present in the jaw, the orthodontist can request the next baby tooth in line on each side (the baby cuspid tooth) to be removed early. This will allow the front teeth to align better as they grow in. The will usually straighten about 80% if given 6 to 10 months.

Unfortunately, this treatment does not increase the size of space available for teeth in the jaw. It does move the problem further back in the mouth. At age 10 1/2 or 11 when the mid range teeth (bicuspids) start to grow in and push out the first of the baby molars, a second evaluation will be done. If it is decided there is not sufficient room for all the adult teeth to fit, one adult tooth (the first bicuspid) can be removed from each side of the arch to allow room for the remaining teeth to grow in. The remaining teeth usually take about 18 months to grow in. It is recommended that braces be used to complete the alignment of the teeth at this point.

There are many complicating factors in the growth and eruption of teeth. This is why it is important for an orthodontist to guide this early part of serial extraction treatment. Complete diagnostic records including panoramic x-ray, diagnostic photos and a cephalometric x-ray are necessary for the orthodontist to provide a proper diagnosis and plan.

The orthodontist will provide a written request to your dentist for teeth to be removed at the most appropriate time.

Retainer – or – Braces Which one is best?

Both retainers and braces can move teeth. The secret to moving teeth is very small amounts of pressure applied constantly. Both appliances can provide the pressure part of the process. The braces are more reliable on consistency of effort. Retainers, be they with wire or clear aligners are removed for eating, brushing etc. At best they are not as consistent as braces as applying the needed pressure.

The retainer can do the job, but it will usually take longer.

The braces can also be adjusted more accurately than a retainer. The spring of a retainer is bent and re-bent every time it is placed on the teeth. This can change the pressure level of the spring being used to place pressure on a tooth.

Even for small touch-up treatments, often braces for a few months can be far more effective than a treatment retainer used for 6 months. Also, braces can be used to make space for a blocked tooth far more easily than can a retainer. Lastly, braces can change the vertical position of a tooth. Retainers are very limited in this type of movement.

How to choose the best orthodontist for your child

Choosing your orthodontist can be simple or complex depending on you. Orthodontic treatment takes a year or three and there will be regular visits with the dentist and their staff. You should choose an orthodontist you feel comfortable talking with as well as one who will spend the time needed to make a great smile.

We recommend you speak with more than one orthodontist. For most orthodontists this initial meeting and evaluation is complementary. It will cost you only the time needed, probably about an hour.

Orthodontic treatment, even limited or minor treatment moves and changes all the teeth of the mouth as well as the function of the jaw and muscles. This is complex care and requires an excellent understanding of what will happen. A thorough understanding of facial growth and development is also required for providing orthodontic treatment for growing children.

HMO insurance requires you to see a contracted orthodontist. Ask your dentist or check the insurance web site to see who is in network. PPO insurance plans provide better benefits if you see an in-network orthodontist, but it is not required.

Many general practice dentists provide orthodontic care using Invisalign (TM) aligners. Orthodontists have spend at least two additional years of training at a recognized and accredited university. Look for a member of the American Association of Orthodontists.

Braces, first visit. What will happen?

You or your child’s first visit to the orthodontist may have been recommended by your family dentist, or, you may have concerns of your own. Our office welcomes new families and offers an initial evaluation without charge. Some insurances require a written referral. If this is needed, we will contact your dentist for the form.

If there are specific concerns, please let the orthodontist know at the start of the appointment so we can be sure to address them. If the concern is in regards to a tooth not at the surface (stuck or impacted) please bring the x-ray from the dentist’s office with you to the appointment. This can be either printed, digital or e-mailed.

If you have insurance that covers braces, bring the insurance card, or information with you to the visit.

The orthodontist will do a thorough evaluation and may request a panoramic x-ray or other imaging at the first visit to provide better information regarding the specific patient’s needs.  You will be given an outline of the issues to be resolved and the basic treatment to do this.

A detailed diagnosis and treatment plan will be done after more complete diagnostic records can be evaluated. No one likes surprises, and the orthodontist will need the complete diagnostic records to firm up the care plan.

You will leave after the first visit with an estimated plan and fee for the treatment. Some insurances require their dentist to evaluate the records prior to their authorization of care.

The first visit should take from 30 minutes to an hour of your time.

My 7 year old has spaces between the teeth?

A small space between the front teeth of a 7 year old, less than 1 MM, is normal. However, if the space is greater than one millimeter or there are additional spaces between the other upper front adult teeth this can cause a problem for the next tooth in line.

Often, when the front teeth are spaced widely, the cuspids, or eye teeth, often do not have sufficient room to fit in line. They can push out forward of the other teeth, appearing as fangs. If the room for the cuspids is very limited, they can also take an alternate path and become stuck in the bone behind the front teeth. This takes considerable effort and resources to correct often including an oral surgery procedure to uncover the stuck teeth.

Crowded teeth?

There is a range of crowding of teeth. There are three ways to reduce crowding of teeth.

First, is to move all the teeth in the arch more forward, into a larger circle to get the extra room. If there is enough bone on the face side of the teeth this works well.

Second, is to reduce the width of individual or multiple teeth by sanding. If the teeth are not as wide, they will fit in line better. This method can often be combined with the first method.

Third, if there is not enough bone to contain all the teeth when they are aligned, teeth can be removed from the line to provide enough room to align the others. If there is not sufficient room in the bone, and the teeth are forced into alignment, they will have gum recession and bone support problems. Most often two teeth (one from each side of the mouth) are removed so the mouth is symmetric when the teeth are aligned.