Chapter 17: Orthodontic Treatment

The aim of orthodontic management is to straighten and align the teeth and adjust the dental arch forms so that the teeth fit together correctly. The accurate positioning of the teeth plays a part in:

• the appearance and self-esteem of the child
• good speech patterns
• normal function of the teeth and gums
• good health

Irregularities of the primary teeth are usually minor and not significant. If they are lost early, however, malocclusion, or bad locking together of the teeth, may occur or be worsened. During the time that the permanent teeth are erupting, one or more may appear slightly out of line or may even erupt into the palate. There may be missing, or even extra, teeth. No teeth should be removed without consultation with the dentist or orthodontist of the Cleft Palate Clinic. All permanent teeth are important for the growth and development of the upper jaw and they may be moved into position where they will grow normally. The presence of all the permanent teeth without major decay will allow the orthodontist to move teeth into normal positions later.

To aid in assessing the development of the mouth and face structures and to evaluate treatment for each individual case, careful progress records need to be collected. These take the form of:

• X-rays used to document the presence and position of teeth under the gum, to reveal any abnormalities of shape, number, and health of the teeth, and to give a picture of how the jaws are located in relation to the other bones of the skull.
• Impressions (made with special moulding paste) from which plaster casts of the full set of teeth are made. The casts provide an important three dimensional replica of the positions of all the teeth.
• Photographs of teeth, mouth and facial features.

17.1 Primary Dentition


17.2 Mixed Dentition

Most children will need orthodontic treatment of one form or another after most of the permanent teeth have erupted at about 12-14 years. The exact form that this treatment takes must be individually planned because each child has his/her own particular problems. Most management plans are carried out in stages for the best results.

The orthodontist will use fixed appliances, or braces, which enable fully controlled tooth movements. Most frequently, the fixed appliance consists of braces or brackets cemented to the teeth. Flexible archwires are then shaped and fixed to the brackets, and the teeth are moved by the forces applied by the attached archwires. Force may also be supplied by elastic bands and miniature wire springs for special tooth movement. Another type of orthodontic appliance commonly used for widening or expanding the cleft dental arch is a specially shaped wire that is attached to metal bands onto the molar teeth. This expansion appliance pushes the teeth outwards from the inside, or palatal side, of the upper teeth.

When the orthodontic treatment is completed, the appliances can be readily taken off, and a removable appliance (or retainer) will probably be needed for at least a few months to hold the teeth in their corrected positions. This retainer is usually made of plastic and wire. Although it will be removable, the greatest benefit is obtained by wearing the retainer strictly according to your orthodontist's instructions, which usually require use at all times except mealtimes. Whether or not the appliance is worn while eating, it is essential to clean it with a toothbrush whenever the teeth are being cleaned, because dental plaque will grow on the appliance as well as on the teeth. Orthodontic appliances have been blamed for 'rotting the teeth', but this 'rotting', or dental decay, is the result of not removing the dental plaque. Sticky sweets, besides being bad for the teeth, are also bad because they can cause loosening of braces that are cemented to the teeth.

Some children may later require dental bridges to replace missing teeth. The dentist usually prefers to delay making such bridges or other more complex prostheses (artificial replacements) until the child is in the late teens and the teeth have reached an appropriate degree of maturity to support the prosthesis. As noted in the next section, however, the use of bone grafting may be diminishing the need for prostheses.

17.3 Before Expansion


17.4 Expansion device in place


17.5 Before orthodontics


17.6 After orthodontics

Further Information

To obtain further information on "Cleft Lip and Palate: A Parent's Guide", please contact Belinda Liston:

Belina Liston
Cleft Palate Clinic Coordinator
The Cleft Palate Clinic
The Children's Hospital at Westmead
Locked Bag 4001
WESTMEAD NSW 2145
AUSTRALIA
T: + 61 2 9845 2079
F: + 61 2 9845 2078
E: BelindaS4@chw.edu.au