The care for a cleft lip/palate child requires a number of interventions and treatments to bring the parts of the face an mouth back to ideal. These treatment start at birth and are initiated at specific, critical times during growth of the face and teeth.
NAM treatment: Nasal Alveolar Molding started at birth, to re-position and align the gum sections of the upper jaw, reshape the nose and reduce the tension on the cleft lip. The cartilage of the nose can be reshaped for the first 3 months of life. After this early period, they can not be reshaped. The shape of the nose at four months of age will be the shape for the rest of the life. It will grow but not change shape. This treatment can be done with a retainer like device and/or a nasal conformer with various lip tapes. The initial lip and nose surgery is usually done at 3 to 4 months of age.
Alveolar Bone Graft Treatment: The initial lip an nose surgery does not close the gap in the gum. The gum surgery is usually done at age 9 to 11 and is based on the growth of adult teeth in the cleft area, not the child’s age. At age 7 the child will be evaluated with an x-ray to see how close teeth are to the gap in the gums. The gap will be closed just in time so the teeth will grow all the way to the other upper teeth. At this time, the upper jaw usually needs to be reshaped with palate expansion to match the shape of the lower jaw. Also, the upper front tooth usually grows turned 90 degrees from ideal. This alignment issue is also addressed. The lower front teeth, often in front of the upper front teeth are straightened, and a retainer places to keep them from over-growing. The upper jaw may be a little behind the lower jaw creating an underbite.
Adolescent Treatment: At age 13 to 14 when all the remaining adult teeth have grown into the mouth, the teeth are aligned. This step is often combined with the mixed dentition treatment.
Adult Treatment: When the face has completed growth, the upper jaw has often not kept up with the other bones and there is an underbite. At this age braces are placed on all teeth, the dental alignment refined and the upper jaw is moved forward with surgery (LeForte) to catch up with the rest of the face. Final lip an nose surgery is usually done six months after the upper jaw surgery.
QuickBraces, FastBraces®, Six Month Smiles® treatment. Do they work?
Teeth move through bone of the jaw using your body’s natural physiology for bone reshaping. So far, there has been no breakthrough in changing how the body’s system works. All braces work the same. They push a tooth with very slight pressure in a constant direction, and the bone of the body reshapes very slowly around the tooth to allow it to move.
There are many brands (manufacturers) of braces. They come in a variety of shapes and sizes. Your teeth do not know what brand of braces they are wearing, and don’t read the advertising saying one works faster than another.
There have been some experimental orthodontic techniques using multiple surgical holes punched into the bone between the teeth to increase the bone metabolism for a month or two after the surgery. This seem promising, but a little extreme, and expensive.
There are many well trained and very smart orthodontists in the San Diego area. They will tell you that a typical treatment takes 2 to 3 years. If they could routinely treat the same smiles to the same quality in 6 months, they would all be doing this treatment. It is curious that not one of the dentists listed as providers for FastBraces® or Six Month Smiles® in San Diego are orthodontists.
Teeth can change positions for a number of reasons including facial growth after braces are completed, gum disease, accidents, and not wearing a retainer or a bonded (fixed) retainer breaking.
If the tooth movement is due to gum disease or trauma, these health issues needs to be addressed by the dentist and/or periodontist prior to aligning the teeth.
If the out of line tooth has room in the line, often a treatment retainer with a spring to re-position the misaligned tooth can be effective.
If the tooth out of line does not have enough room to move back into line, more room needs to be made first, this is a ‘touch-up treatment’. This can not be done with a retainer alone. A touch up treatment needs braces for only a few (3 – 6) months and then back into a passive retainer.
If tooth misalignment is due to adverse post-treatment facial growth, the bones of the face may require re-positioning to align the teeth. Surgeons request to have full braces and ‘surgical wires’ placed prior to the surgery.
Everyone knows what braces and Invisalign™ look like. But can they do the same things? Do they cost the same? Can they adapt the same to changing needs during a treatment?
These are all important questions! The answers may surprise you.
Braces come in several sizes and types. Large & small metal brackets, and clear brackets. The brackets are nothing more than handles on the teeth. By themselves, they do nothing. No matter what type of brackets are used, the wire between the braces only comes in metal. The wire is a spring which moves the teeth into alignment.
Invisalign (TM) is a series of clear plastic retainers which move the teeth incrementally with each change of appliance. Each one is worn for 2 to 4 weeks before changing to the next aligner. Depending on the specific needs of the patient, there are usually acrylic “handles” bonded to most of the teeth much like brackets of braces. Aligners have difficulty with certain types of tooth movement, like vertical changes of the arch or rotations of corner teeth. Aligners must be removed for eating. All the aligners are made to the Doctor’s prescription by technicians. The aligner company permits one mid-treatment course adjustment. The cost of the aligner appliances is significantly higher than braces. The cost in San Diego for Invisalign™ treatment is $1500 – $2000 higher than for an equivalent treatment with braces.
Braces are on the teeth all the time. Aligners can be removed, and/or forgotten to be put back on the teeth for an extended time. Orthodontic tooth movement works best with very light pressure. Braces can adjust this pressure to accommodate to differing treatment needs. The braces can be infinitely adjusted and have more flexibility to complete the finished smile. Braces can also use elastics (rubber bands) between the upper and lower teeth to adjust the bite more quickly. Braces have added control over the positions of the roots of the teeth. Roots not being aligned is one of the reasons spaces re-open after treatment.
Team Braces requires all patients who wore braces to wear their retainer for one year all the time, except when eating or brushing, after the braces are removed. After one year of full time wear, the retainer can be worn at every night. For younger patients, the every night wear should continue to age 22. For adult patients, the every night wear should continue for an additional year.
After these requirements have been met, you may reduce the amount the retainer is worn. If the retainers are discontinued, teeth will resume normal physiologic changes to position with age. This often means return of some crowding or spacing of the front teeth.
The first year after braces are removed the retainer provides two functions. First, the chewing surfaces of the back teeth need to wear into their new positions. This is a slow process and can take up to six months. Second, the bone holding the teeth needs to harden as it is softened a little during active treatment.
Teeth move slowly from the back of the mouth toward the front your entire life. This is why teeth will change position when ever retainers are discontinued.
Problems with braces can include a poking wire, loose or broken brace or a lost retainer.
Poking wire, usually behind the last brace, can scratch the cheek. A first temporary fix for this is to use the wax or silicone given to you by the office. Take a pea sized amount, work it with your fingers until soft, then mold the wax around the poking wire and the brace. This will give temporary relief. Contact the office to have the wire trimmed as soon as possible.
Loose and/or broken brace. If this is the last brace in the line, the wire will start to scratch the cheek. If the brace is not the last brace in line, it will slide or turn on the wire, but not cause an immediate problem. If a brace is loose and/or broken, please notify the office immediately so we can plan enough time to repair the brace at the next visit. We may need to change your appointment to an earlier visit for this to be done. If you do not let us know about a broken appliance before you arrive, there may not be time available for it to be fixed.
Lost retainers can not do their job. Please let us know immediately if a retainer has been lost so it can be replaced. Teeth will move out of line if a retainer is not being worn as requested. You can use the temporary (clear) retainer while waiting for the Hawley (wired) retainer to be replaced.
Some children do not grow the size, or shape of the upper jaw to fit the lower jaw properly. The upper jaw is often too narrow. A narrow upper jaw makes less room for the upper teeth to fit. If not corrected, this can often lead to “fangs” as a teenager. It can also cause more serious conditions such as impacted upper eye teeth. This condition can require surgery for correction.
The expander is attached to and uses the teeth to push on and widen the upper jaw. Expansion is most effective when the child is age 6 to 10. After age 12 or so a successful expansion may also require a major jaw surgery.
It is easier, more effective, and more stable to do expansion at an early age.
Children should be seen for their first braces check-up at age 7. At this age the space for teeth is pretty well set and the orthodontist can tell if there are any issues which would benefit from early treatment. The primary reason for starting with an early evaluation is to get the best plan for your child. Some issues are important to start early, like crossbites and palate expansion. The older the child, the more complications can occur from these issues. Children with early loss of back baby teeth need spacers to keep the adult teeth from drifting and blocking other teeth. Some of the teeth alignment problems, like individual front tooth crossbite can cause permanent damage to both teeth and bone.
Every child is different and we design the treatment plan specifically for your child, often waiting for a later age to start braces.