Full text of DOI:10.1038/sj.bdj.4800410a

PRACTICE
cleft lip and palate
Dental care for the patient with a cleft lip
and palate. Part 2: The mixed dentition
stage through to adolescence and young
adulthood
1
2
3
4
C. J. Rivkin, O. Keith, P. J. M. Crawford, and I. S. Hathorn,
for all children, this section aims to high-
light aspects of dental care which are partic-
ularly important for children with a cleft.
Dietary counselling is best achieved with
a three-day diet diary. This is a procedure
that can be carried out at any stage of the
child’s dental development, especially when
there is a caries problem. Erosive tooth sur-
This is the second of two articles looking at dental care for the
patient with a cleft lip and palate. Part 1 looked at the needs of
the child from birth through to the mixed dentition stage. Part 2
looks at dental care from the mixed dentition stage through to
adolescence and young adulthood.
4,5
The mixed dentition stage
As in the early years, the main emphasis help the child and support the family.
throughout the mixed dentition stage Parents become increasingly keen for the this age group. Any observed tooth wear
by the cleft team is sometimes required to face loss due to the excessive intake of acidic
food or drink is also a potential problem in
should be on the prevention of dental dis- orthodontic treatment to start if the upper needs to be carefully monitored and
6
ease. The dentist has an important role in permanent anterior teeth erupt into addressed.
helping to balance the child’s developing unfavourable positions. The teeth in the
independence with a continuing need for cleft region can show marked rotations, or
parental help and supervision. This is the retroclination combined with anterior
period when the child should be encour- crossbite. Hypodontia is also a problem,
In brief
aged to start accepting responsibility for his with the upper permanent lateral incisor • The patient is encouraged to start
own dental health and learn how to look commonly missing. The increased tendency
after his mouth. towards a Class III incisal relationship may
Accepting the appearance of the cleft and become more apparent at this stage (Fig. 1).
accepting responsibility for his or her
own dental health with prevention
playing a key role.
the teeth in this region is often a big hurdle The dentist can provide valuable support • Teasing at school can be a problem.
for some patients and their parents. By and reassurance with regard to these devel- • Patience, support and skilful behaviour
working together closely with the parent opments. The patient and family are
management are important.
and child, any anxieties can be more readily encouraged to focus on the continuing • Patient motivation can decrease in the
identified and overcome. In general, society importance of the prevention of dental dis-
reacts negatively to facial disfigurement1 ease and the maintenance of oral health.
teenage years. Multiple visits for cleft-
related care are a factor.
and many patients with a cleft lip and palate
In some cases, orthodontic treatment is • Good communication with the cleft
experience problems with teasing at started early. For example, a simple upper
school. Psychological counselling arranged removable appliance may be provided to
team is essential. Dental extractions
should be carried out only after consul-
tation with the orthodontist involved
with cleft care.
2
correct an anterior crossbite. Patients with an
alveolar cleft may require orthodontic
1Senior Community Dental Officer, Honorary
expansion with a fixed appliance (Fig. 2) to
create space for placement of an alveolar
bone graft. The alveolar bone graft is usually
carried out between the ages of 8–10 years.
Lecturer in Paediatric Dentistry, Specialist in
Paediatric Dentistry, Community Unit, Division of
Child Dental Health, Bristol Dental Hospital, Lower
Difficulties with toothbrushing often
2
Maudlin Street, Bristol BS1 2LY Consultant
The aim of this surgical procedure is to repair arise as the upper permanent incisors erupt,
the residual bony defect to allow the eruption due to lack of sulcus depth and tightness of
of the permanent lateral incisor and canine the repaired lip. As in the primary dentition,
tooth into the cleft region. Definitive ortho- the upper permanent central incisors in the
dontic treatment is carried out when the per- patient with a bilateral cleft lip and palate
Orthodontist, Maxillofacial Unit, Derbyshire Royal
Infirmary, London Road, Derby DE1 2QY
Consultant Senior Lecturer in Paediatric Dentistry,
3
Division of Child Dental Health, Bristol Dental
Hospital, Lower Maudlin Street, Bristol BS1 2LY
3
4
Consultant Orthodontist, Division of Child Dental
Health, Bristol Dental Hospital, Lower Maudlin
Street, Bristol BS1 2LY
manent dentition is fully erupted.
may be severely retroclined. Simple mea-
sures such as showing the child and parent
the cleft region in a hand mirror and dis-
REFEREED PAPER
Preventive management
Received 17.03.98; accepted 04.06.99
©
British Dental Journal 2000; 188: 131–134
Whilst preventive management is essential closing the plaque deposits, especially on
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 3, FEBRUARY 12 2000
131

PRACTICE
cleft lip and palate
Fig. 1A Class III incisal
relationship in a 7 year-old child
with a bilateral cleft lip and
palate.
the teeth around the cleft, will assist with
toothbrushing instruction. This will also
help the child to come to terms with the
appearance of the cleft and the associated
teeth.
Worries about bleeding from inflamed Fig. 2 A 9 year-old child
with a bilateral cleft lip and
palate, wearing a fixed
appliance to expand the
upper arch prior to an
gingivae around the cleft region should be
identified. The child and parent can be ner-
vous about brushing the area for fear of trau-
matising the soft tissues, especially following alveolar bone graft. A
alveolar bone graft surgery. Oral hygiene
supernumerary tooth is
visible in the left cleft region
prior to bone grafting must be of a very high
of the palate.
standard as gingival inflammation can cause
7
loss of the new bone. A 0.2% chlorhexidine
gluconate mouthwash is useful for short
periods following surgery or to help stabilise
gingival health in severe cases of gingival
inflammation, where the patient is anxious
about the bleeding gingival tissues and is
nervous to brush. However, there is no sub-
stitute for good toothbrushing and this
should be re-established as soon as possible.
Access to the teeth in the cleft region is
often difficult and a baby-sized toothbrush
Fig. 3 Bilateral cleft lip and
is still useful even at this age, especially
where the upper lip is tight. This can be sup-
plemented with an interspace brush. Teeth lateral incisor in the palatal
often need to be targeted individually when
palate in an 8 year-old child
showing the left primary
cleft.
toothbrushing, as conventional brushing
round the arch will exclude abnormally
positioned teeth in the cleft region, particu- cial mention. Home use of disclosing tablets until at least 7–8 years of age.
larly those placed palatally (Fig. 3). The and the importance of a hand-held or bath-
Fissure sealants are an important consid-
8
child is shown how to lift the upper lip out room mirror to aid toothbrushing should eration for this group of patients. The pro-
of the way to facilitate brushing (Fig. 4). The be discussed. Parental support with tooth- cedure is advisable for first and second
cleaning of any anterior teeth positioned brushing is helpful throughout the mixed permanent molars, and premolars where
high in the labial sulcus should be given spe- dentition period and supervision is advised indicated. Fissure sealing should be carried
out as soon as the teeth have erupted suffi-
ciently to allow adequate moisture control
of the occlusal surfaces.
The application of fluoride varnish is a
valuable preventive measure. It is particu-
larly useful for hypoplastic permanent
incisors, areas of early demineralisation,
teeth in the cleft region and partially-
erupted permanent molars prior to fissure
sealing. Fluoride tablet supplements should
Fig. 4 Toothbrushing
instruction — an 11 year-old
child with a bilateral cleft lip
and palate being shown
how to lift the upper lip for
good access to the cleft
region.
be continued throughout this phase if
appropriate, or fluoride mouthwash usage
could be introduced at this stage if only a
topical effect is required.
132
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 3, FEBRUARY 12 2000

PRACTICE
cleft lip and palate
Fig. 5 A 20 year-old patient
with a cleft of the soft palate
only. Needlephobic. Multiple
carious lesions.
Radiographic management
Patients with a cleft lip and palate require
many radiographs to monitor growth and
development, facilitate planning for ortho-
dontic treatment or surgery and assess out- advice are important. Adhesive restorations dontic treatment. Patients with a cleft lip
come and stability. Clear guidelines are laid can be placed to protect these teeth, make and palate often undergo a long course of
out regarding the recommended frequency them easier to clean and improve their aes- appliance therapy, sometimes in conjunc-
of radiographs to diagnose or monitor thetics. These restorations can serve as an tion with orthognathic surgery to correct
9
caries. For comprehensive dental care, the interim measure prior to more advanced the jaw relationship.
bitewing radiograph (or lateral oblique view restorative work carried out in the young
Once again the main role of the dentist
in the less co-operative patient) is essential adult years following the completion of is to help the patient maintain good oral
1
1
to permit thorough treatment planning. orthodontic treatment and possible surgery. health and prevent dental disease. Dur-
Further radiographs will be required, as Improvement of appearance is of crucial ing the teenage years the patient can lack
motivation and find it difficult to visualise
the end result of the orthodontic treat-
ment. Peer group pressures are strong and
school commitments become more
demanding. Missed dental appointments
may occur. It is important to be aware that
patients with clefts are not necessarily as
dentally-motivated as routine orthodontic
Fig. 6 A 37 year-old patient
with a left unilateral cleft lip
and palate who attended
Bristol Dental Hospital in
pain. Neglected oral health.
Last dental attendance at 14
years - he disliked multiple
visits for cleft-related care.
patients. The latter are a selected group
who have chosen to proceed with ortho-
dontic treatment. The dentist is in a posi-
tion to encourage and support the patient
in carrying out the appropriate preventive
measures and making him aware of the
importance of attending both orthodontic
necessary, to investigate the developing den- importance for patients with a cleft lip and and regular dental check-up appoint-
tition and any pathology, trauma, or other palate, who may be subject to teasing and ments. The adolescent with a cleft may
dental conditions.
suffer from a poor self-image.
have to make multiple hospital visits for
cleft-related care in addition to other pos-
sible medical problems and this should be
Restorative care
Communication with the cleft team
If restorative work is needed it should be car- Good communication with the cleft team taken into account.
ried out to a high standard. Pulp treatment becomes particularly important from the
procedures and stainless steel crowns for pri- mixed dentition stage onwards, as ortho- Preventive management
mary molars should be used where appro- dontic treatment is often started early for Messages about oral health need to be given
priate. The aim is for these teeth to exfoliate this group of patients. Teeth with a poor repeatedly and kept simple. Positive rein-
naturally, thereby maintaining the original prognosis should be discussed with the forcement should be given to encourage the
arch relationships and space for the perma- orthodontist involved with cleft care. patient to maintain or improve their moti-
nent successors, unless extractions are indi- Extractions should be carried out only after vation. Dietary counselling continues to be
cated for orthodontic reasons. Sealant consultation with the orthodontist. The of paramount importance. The patient
restorations provide a solution to the early dentist should ensure that the child is seen needs to be made aware of the potential
carious lesion, especially in the occlusal sur- regularly throughout any course of ortho- problem of decalcification around the
faces of permanent molar teeth.10
dontic treatment for specific toothbrushing orthodontic brackets and other dental
The upper permanent incisor teeth can instruction, reinforcement of dietary advice caries problems if the frequency and
show varying degrees of hypoplasia in the and the use of a fluoride mouthrinse where amount of sugar intake is not controlled.
patient with a cleft lip and palate. This can necessary.
range from mild hypoplasia to a marked loss
of tooth substance. Teeth with marked The permanent dentition —
hypoplasia can be sensitive and difficult to adolescence to adulthood
Acidic foods and beverages need to be regu-
lated to avoid the possibility of erosion. A
three-day diet diary may again be indicated.
Written instructions, in addition to verbal
keep clean giving rise to gingival inflamma- The presence of the permanent dentition advice, are helpful for the patient to refer to
tion. Reassurance and careful preventive usually heralds the start of definitive ortho- at home.
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 3, FEBRUARY 12 2000
133

PRACTICE
cleft lip and palate
Regular oral hygiene monitoring and denture (possibly combined with an upper Lip and Palate Association was incorect in
instruction is necessary, especially if fixed retainer) are sometimes necessary. The the first part of this article (Br Dent J 2000;
appliances are being worn. A toothbrush patient’s dental health needs to be stable 188: 78–83). The correct address is 235–237
with a small head is recommended and the before advanced restorative techniques can Finchley Road, London NW3 6LS.
interspace brush and twinspiral brush are be considered. The dentist needs to make
valuable interdental aids. When fixed the patient aware of the importance of long-
appliances are not being worn the use of term preventive care and regular dental
dental floss may be appropriate. The regu- check ups.
1
2
Bull R H C. Society’s reactions to facial disfig-
urements. Dent Update 1990; 17: 202-205.
Turner S R, Thomas P, Dowell T, Rumsey N,
Sandy J R. Psychological outcomes amongst
cleft patients and their families. Br J Plast Surg
lar use of disclosing tablets should be
encouraged for all patients. Toothbrushing Communication with the cleft team
can be particularly difficult around the In addition to seeing the orthodontist, the
cleft region in the early stages of fixed adolescent with a cleft may have consulta-
appliance therapy where there is marked tions with the maxillo-facial surgeon if
misalignment of teeth. Any unrestored orthognathic surgery is planned. The plastic
hypoplastic teeth may provide potential surgeon may be seen to discuss the need for
1997; 50: 1-9.
3
4
Roberts-Harry D, Sandy J R. Repair of cleft
lip and palate: 1. Surgical techniques.Dent
Update 1992; 19: 418-423.
Andlaw R J, Rock W P. A Manual of Paediatric
Dentistry (4th ed) Edinburgh: Churchill
Livingstone, 1996.
areas for plaque accumulation.
further reconstructive surgery. The consul-
5
6
Welbury R. Paediatric Dentistry. Oxford:
Oxford Univ Press, 1997.
Professionally-applied topical fluoride, in tant in restorative dentistry will be involved
the form of fluoride varnish, continues to be with the planning and timing of any com-
useful, particularly in the cleft region, plex restorative work.
Millward A, Shaw L, Smith A J , Rippin J W,
Harrington E. The distribution and severity
of tooth wear and the relationship between
erosion and dietary constituents in a group of
children. Int J Paediatr Dent 1994; 4:
151-157.
Bergland O, Semb G, Abyholm F E.
Elimination of the residual alveolar cleft by
secondary bone grafting and subsequent
orthodontic treatment. Cleft Palate J 1986; 23:
around hypoplastic teeth and in areas of
early demineralisation. Patient-applied top- whelmed and confused by all the different
The patient may be emotionally over-
13
ical fluoride in the form of a mouthrinse aspects of his cleft care. The dentist needs
daily or weekly) is worthwhile especially to be sensitive to the needs of the patient,
during orthodontic treatment. using time and patience to maintain good
7
(
It is essential that the patient with a cleft is communication during the teenage years. It
monitored closely and that regular dental is important that the dentist raises any con-
care is maintained at all times. During the cerns about the patient with the cleft team.
transition from teenage years to adulthood Psychological counselling is available for
the patient will need to be encouraged to patients with a cleft who feel that they are
accept responsibility for his own dental unable to cope with their problems or dis-
175-205.
8
9
British Society of Paediatric Dentistry: A
Policy Document on Fissure Sealants. Int J
Paediatr Dent 1993; 3: 99-100.
Pitts N B, Kidd E A M. The prescription and
timing of bitewing radiography in the diagno-
sis and management of dental caries: contem-
porary recommendations. Br Dent J 1992;
2,14
health, with prevention playing a key role cuss their worries.
Figs 5 and 6).
172: 225-227.
(
1
0
1
Crawford P J M. Sealant restorations (preven-
tive resin restorations). An addition to the
NHS armamentarium. Br Dent J 1988; 165:
250-253.
Hall R K. Care of adolescents with cleft lip
and palate: the role of the general dental prac-
titioner. Int Dent J 1986; 36: 120-130.
Summary
Patients with a cleft lip and palate are a pri-
Restorative care
Restorations required as a result of caries ority group. The dentist has a key role to
should be carried out prior to the start of play in providing continuing, high-quality,
orthodontic treatment, and regularly preventive-based dental care. Thorough
1
reviewed and maintained throughout this treatment-planning, patient support and 12 Burke F J T, Shaw W C. Aesthetic tooth mod-
ification for patients with cleft lip and palate.
Br J Orthod 1992; 19: 311-317.
period. Adhesive restorative techniques for skilful behaviour management are impor-
the remodelling of tooth form, composite or tant aspects of this multi-faceted care. Good
1
3
4
Canady J W. Emotional effects of plastic
surgery on the adolescent with a cleft. Cleft
Palate Craniofac J 1995; 32: 120-124.
Thomas P, Turner S R, Rumsey N, Dowell T,
Sandy J R. Satisfaction with facial appearance
among subjects affected by a cleft. Cleft Palate
Craniofac J 1997; 34: 226-231.
porcelain veneers and resin bonded bridges communication on a regular basis between
are used to achieve aesthetic improvements the dentist and relevant members of the cleft
after the completion of orthodontic treat- team helps to achieve the best oral health
1
12
ment. Conventional crowns and bridges outcome for the patient.
or the provision of a chrome-cobalt partial Note added in proof: The address of the Cleft
134
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