Congenital disorders

Cleft Palate      

What orthodontic treatment is recommended for a child born with a cleft palate? 

According to an assessment based on the Israel Ministry of Health's data, 80 – 100 children (Jewish and Non-Jewish) are born annually, with a congenital cleft lip, palate or both. In some of the cases this is already detected in the ultra-sound systems scan performed during pregnancy.

Babies born with cleft palates are treated in a number of units for treatment of congenital malformations in some medical centers throughout Israel. Treatment is individual for each infant, according to his/her deformity. 

For infants born with a cleft lip (a relatively rare phenomenon and in varying degrees of severity), the parents face a psychological challenge of how to cope emotionally with such a baby. Undoubtedly, issues of esthetics and psychology will later be encountered by the child himself, depending on the severity of the deformity and the quality and degree of success of the corrective plastic surgery to close the cleft.
Most children in this group will not have any problems related to orthodontics or to speech and hearing.

Children born with cleft palates (in varying degrees of severity) have the immediate problem of feeding. They are unable to create "sub-pressure" in the mouth and therefore are usually unable to breast-feed.  In many centers, where orthodontic treatment is accessible, an attempt is made to facilitate feeding by a special plate (obturator). The child is under observation and is aided by the plate for a year, until surgery for closing the palate is performed. During this period, due to constant growth, the plate has to be replaced once or twice.

Where there is no access to an orthodontist, an attempt is made to feed the child with special nipples and bottles, and skilled staff are trained in order to direct parents how to feed the baby. 

Children who are born with a cleft palate do not present any problem with the number of teeth, but usually with closure. It is commonly assumed that due to a lack of palate tissue and to the surgery for closure of the palate, scar tissue is formed on the palate and consequently the upper arch becomes narrow, resulting in cross bite of the posterior teeth, uni- or bi-laterally. This can result in malfunctioning: in more severe cases, the palatal scar tissue may influence proper facial growth, mainly of the central third, and manifests in incorrect coordination of the jaws, meaning, formation of an anterior cross bite resulting in the protrusion of the lower jaw. Obviously these children will require special orthodontic treatment – as specified below.
 
Children born with a cleft palate may develop caries (tooth decay) more often than children born without. Moreover, these children must be continuously observed/examined and receive hearing and speech therapy, since many suffer from auditory deterioration and their speech is nasalized (speech through the nose). 

The third group (the largest in number of children) is that of children born with a cleft lip, alveolar bone (on which the upper teeth are to erupt) and palate (which, in the minority of cases, does not exist). The degree of severity of the cleft may vary from slight to serious, it may be uni- or bi-lateral and occasionally accompanied by severe distortion of the upper dental arch.

Most children in this group also manifest nostril deformity. In this case, immediately after birth a feeding plate should be prepared, as mentioned above. The orthodontist utilizes this plate, as well as other aids, to perform pre-surgical orthopedic treatment, in order to draw the divided segments closer to a more ordered dental arch, to facilitate the plastic surgeon's performance of closure of the cleft palate. By means of an addition to the plate, nasal moulding is also executed.
These children must later undergo surgery to close the cleft lip and thereafter the cleft palate (if this was the case). 

These children – more so than children born with only a cleft palate – must be under observation/be examined and receive therapy for hearing and speech, because many of them suffer a loss of hearing and have nasal speech.

These children present a range of challenges related to their morphological structure and the number of teeth, their positioning, closure, functioning and facial esthetics.

Sometimes, with an alveolar cleft there may be certain redundant teeth (treatment of these cases is relatively simple – excess teeth are extracted), but usually there is an inborn lack of certain teeth (usually the lateral incisor in the upper dental arch).

In the area of the cleft, in many instances, the morphology of the teeth is impaired, as are usually their structure and position. Furthermore, as mentioned previously regarding the cleft palate, they develop narrowing of the upper dental arch, malpositioning of the upper back teeth in the arch and in relation to the lower dental arch.

At the age of 8-9, these children must undergo the first stage (sometimes out of three) of orthodontic treatment – to widen the upper arch and its teeth arrangement. At the end of this stage of treatment, of about one year's duration, the children must undergo bone transplant surgery in the divided segments in order to stabilize the teeth and enable correct eruption of adjoining teeth. Towards the end of changing all milk teeth, the children undergo full orthodontic treatment, to achieve proper correlation of each individual arch and between the two arches. This treatment can last from 18 – 24 months.

Towards the end of the growing process, these children need upper lip and nose surgery.  In more severe cases, as mentioned above as well, there is a negative influence on jaw growth: these children must sometimes also undergo a third stage of orthodontic treatment in preparation for "distraction osteogenesis" (stretching of the jaw bone) and/or jaw surgery, to achieve proper jaw closure, better functioning and a more harmonious facial appearance.

Teeth of children with a cleft are more susceptible to caries and, due to numerous orthodontic treatments, they must receive more oral hygiene and dental preservation treatments than children with no clefts.                                

Children diagnosed with a congenital shortage of teeth as well, will, at the end of their orthodontic treatment, require rehabilitative treatment, by means of implants or bridges, common in tooth rehabilitation, in order to achieve the best possible function of the masticatory system, including proper speech. 

The total treatment of these children born with a cleft lip, alveolar bone and/or palate continues, with interruptions, for about 20 years. During this time, the children need, as mentioned previously, 2-3 periods of orthodontic treatment (straightening of teeth and jaws) that is not common and whose purpose is not solely esthetic, but individual to each child, according to his specific problems. 

Orthodontic treatment actually builds the infrastructure upon which the plastic surgeon can perform the necessary final surgical corrections to the lips and nose and the maxillo-facial surgeon the jaw surgery for improvement of facial harmony.

The complete treatment of cleft children is usually performed at special clinics and with special teams, which exist in a number of hospitals. Treatment is usually not performed in private or "public" (government) clinics.  Treatment of a young child obliges parents to bring him to the various clinics, often several times a month, requiring much effort on behalf of the parents, loss of work days and many other expenses.

The financial cost and the part borne by the medical aid funds is not totally clear and varies from one medical aid fund to another. Thus, the issue of routine tooth treatment, despite the likelihood of it being connected to the congenital malformation, is not covered, since it is not included in the "basket of health". The subject of speech training is also not quite clear – in certain cases the medical aid does cover, while in others – they make it difficult for the families.

The situation concerning orthodontics is even worse – mostly, parents receive an undertaking for early treatments of preparing the feeding plate and performance of pre-surgical orthopedic treatment. However, for the orthodontic treatments themselves, as mentioned - in 2-3 stages - parents usually do not receive any undertaking from the medical aid, and, if they do, then it is for one treatment only.

Of course, by the same token that tooth treatment is not included in the "basket of health," there is no medical coverage for children born with a congenital lack of teeth resulting from a cleft and who will require rehabilitative treatments to complement the missing teeth.

A special committee acting on behalf of the Ministry of Health, Division of Tooth Health, recommended expanding the "basket" to include children born with clefts. Until now the recommendations were not accepted and the "basket" was not extended. This should be followed up to see if any changes will occur in the "basket" in the future.