Alveolar clefts and corrective jaw surgery

When a child is born with a cleft lip and/or palate, corrective operations are performed during the first year of life to improve appearance and oral function for eating and learning to speak.  A cleft lip is typically repaired at the age of three months and a cleft palate when the child is about 10-months old. 

If the cleft passes through the tooth-bearing portion of the upper jaw (a complete cleft), the defect in the bone is not corrected in infancy, and additional procedures are needed as the child grows.

This residual cleft occurring in upper jaw consists of a gap in the gum and bony structures, called an alveolar cleft.  At the top of an alveolar cleft, there may be an opening between the mouth and the nose.  In addition, the alveolar cleft may prevent proper eruption of the front teeth; teeth near the cleft are often missing or extra, non-functional teeth may be present. 

The repair of the alveolar or residual cleft in the tooth-bearing portion of the jaw generally occurs between 8 and 11 years of age – this procedure includes insertion of a bone graft to unite the segments of the upper jaw.

In most cases, a palatal expander is used prior to the bone graft, to widen the upper jaw and round out its shape.  The process may enlarge the alveolar cleft during this interim phase.  

“The timing for the bone graft is generally based upon development of the permanent canine teeth, which should have completed one-half to two-thirds of root development,” says Dr. Zachary Peacock, an oral and maxillofacial surgeon at Shriners-Boston. “This is determined by jaw radiographs.  Generally speaking, trying to repair alveolar clefts at an earlier age may restrict growth of the upper jaw,” he explains. “After the bone graft is placed, the developing canine then has support for eruption and comes through the new bone, further strengthening it.”

There are three components to the surgical repair of an alveolar cleft:

1. Any openings between the nose and mouth (oral-nasal fistula) or within the nose (cleft nasal mucosa) are closed to separate the mouth from the nose.
2. Bone marrow is taken from the patient’s hip bone and used to fill the gap between the two segments of the upper jaw.  This will heal and consolidate to unite the two segments of the upper jaw, providing support for teeth.
3. Finally, the gum tissue is closed over the bone graft eliminating the cleft

“After surgery, the patient follows a limited diet of ‘blenderized’ food for a month or so, to avoid chewing on the newly forming bone,” says Dr. Peacock. “

When the remaining permanent teeth erupt, usually at around 12-13 years of age, most children require orthodontics to straighten teeth.  It is important that the orthodontist be part of the team and be aware of the overall plan because 30 percent of patients with complete cleft lip and palate will ultimately need a jaw operation to enlarge the upper jaw  for esthetics and to complete the correction of the bite. 

“We have an orthodontist at Shriners who consults with our patients and their local orthodontists to ensure that we are considering all options to address the needs of each individual child,” explains Dr. Peacock. 

A child with missing or malformed teeth (most commonly the lateral incisor tooth on the side of the cleft) has three options, depending upon both the individual situation and/or preference:

1. Moving well-formed teeth forward with braces. The canine can be brought forward, substituting for the lateral incisor.
2. Inserting a bridge, which is an artificial tooth attached between “capped” teeth or crowns that attach to the teeth on both sides of the missing tooth.
3. Inserting a dental implant into the jaw bone at age 13 years or older.  This may require additional bone grafting several months prior to the placement of the implant.

As the child grows, a temporary retainer with teeth can be created to replace the missing teeth as they await a permanent dental solution.

Once the teeth are straightened and in place, as mentioned above, approximately 30 percent of patients still have a jaw size discrepancy and may need an operation to bring their upper jaw forward and improve bite and appearance. This may be combined with some soft-tissue improvement for the nose and lips after the jaws are aligned.

“While the procedures, orthodontics and dental work do occur over a lengthy time span, the results can be dramatic,” says Dr. Peacock.  “We work to ensure that these children grow up with a much-improved appearance, including a complete set of teeth, normal oral function and a smile to be proud of.”
 

To learn more about cleft lip treatment, or other types of treatment at Shriners-Boston, we encourage you to reach out by calling us at 617-722-3000.

If you’d like to support the children who receive treatment at Shriners-Boston, please consider making a donation to the hospital.