Author: The Cleft Dentist

Updates!

Updates!

Posted on by The Cleft Dentist

Hello! 

It’s been quite a while since my last post, but lots has been going on! My husband and I moved back to Buffalo, NY in July, 2018. Things were busy with the move, starting new jobs, and preparing for our BABY GIRL  to arrive any day now! 

We are so happy to be back in Buffalo, where we first met, and to be around friends and family again. We are also very excited to begin our careers, doing what we are most passionate about. 

Many of you have asked where you can find me in Buffalo to potentially become a patient! It is best to come see me at the hospital, where all specialties are under one roof. I’m at Erie County Medical Center, and the phone number is  716-898-1461.

 

Since I have been back, I had the most amazing experience of presenting at the Oishei Children’s Hospital Craniofacial Meeting in November, 2018. It has always been my dream of working with the people who treated me as a patient when I was young. My plastic surgeon, Dr. Perry, was in attendance, which was such a special moment for me.

 

 

My presentation was on Dental Implants in the Cleft Lip/Palate patient, which you can find more information on from my previous post, right HERE. I presented case reports, research, and the best part was, I even talked about my own treatment!

 

And, just in case you are wondering, my dental implants have been successful, and my husband restored them in October, 2018. I could not be happier, being able to function and smile again. 

That’s it for updates! Please contact me if you are in the Buffalo area and have any questions about treatment. 

Until next time! 

 

Smile Train Interview

Smile Train Interview

Posted on by The Cleft Dentist


Super exciting news!!!

I recently had an interview with Smile Train, and I have the final version of the video for you guys to see first , before it appears on the website.

Smile Train

If you haven’t heard of Smile Train before, it is an international children’s charity with a sustainable approach to a single, solvable problem: cleft lip and palate.

It’s really an amazing organization helping children in 85+ countries.

I became involved with Smile Train when they reached out to me through this blog. I was a special guest at one of their Young Leadership Circle meetings.

It’s an amazing group of such special people who are truly interested in helping patients who don’t have access to care. I have been enjoying being a part of such an organization.

Without further adieu, here is the interview!

Guys,

Can you believe 1 surgery is only $250???

Let’s come together and raise enough for at least one surgery. I’ve created a fundraiser page for my blog. Let’s do it!!! Any amount is appreciated, no matter how small.

CLICK this link or the below picture to go to my donation page.

Thank you so much for watching and reading today. Cleft communities are the best communities!!!

Cleft Palate Repair

Cleft Palate Repair

Posted on by The Cleft Dentist


The second surgery!!! This is always a nice one to be finished with because it’s a major milestone for the baby! The main issues involved with cleft lip & palate are resolved at this point. Up until now, the baby is unable to suck or nurse effectively.  Special feeding cups are used to help the baby eat. Prior to the surgery being done, baby must be off of a bottle and drinking only from the special feeding cups.

It is a difficult surgery to go through because the baby is not used to not having an opening in the roof of the mouth. And also, a baby with stitches in the roof of the mouth can be rather difficult. 

In today’s post, we will discuss the surgery and what’s involved, as well as post-op care. A lot of you have asked:

What’s normal, and what’s not?

So we will dive into that too.

If the NAM appliance has been used, the surgical repair is much less than if it was not used.

This is because the palatal segments will be closer together after the use of the NAM appliance.

Cleft Palate repair is usually around 9-18 months of age

When the cleft palate involves only the back of the palate, this is where the soft palate is. It is called an incomplete soft palate. When the cleft runs the whole length of the palate from front to back, it is called a complete cleft palate. It is possible to only have a cleft lip, only have a cleft palate, or have both. 

Complete Cleft Palate

The surgery is done before speech development occurs so that the child can learn to speak with an intact palate. It is also done after cleft lip repair has been completed. It is performed under general anesthesia, just like the cleft lip repair surgery. It takes between 2 and 6 hours to complete.

The palate is closed in a 3-layer technique.

  1. First the inner layer towards the nose is closed,
  2. Then, the muscles of the palate are closed,
  3. Finally, the tissues in the mouth are closed.

By aligning and closing the muscles of the palate, speech, eating, swallowing, and hearing are improved. 

Why is this surgery important?

Prior to surgery, there is a communication between the mouth and the nose via the roof of the mouth. This surgery helps to close that communication. 

The reason this is important is because it:

  • Allows for formation of a watertight and airtight valve, which is necessary for normal speech 
  • Preserves facial growth
  • Allows for appropriate dental development! 

Tubes for the ears can also be inserted at this appointment.

It is important to remember!

A portion in the front of the palate will be left open to allow the jaw to grow. This will be repaired with the secondary alveolar bone graft. 

What’s normal:

  • More discomfort than cleft lip repair surgery
  • Nasal congestion
  • Staying in the hospital for 1-3 days
  • Stitches on palate that will dissolve over the next 2 weeks
  • Bloody drainage from nose & mouth
  • Swelling, bruising
  • Arm restraints for 2 weeks to make sure baby won’t disturb the site! 

Diet after repair: 

  • Only a cup can be used after the operation
    • A suction via a sippy cup or bottle can disturb the stitches in the mouth due to pressure
  • Mix baby food with fluid in the cup so it can be poured into the mouth
  • NO spoon for a week after surgery (varies from surgeon to surgeon)
  • After eating, always make sure to give child water to rid the mouth of debris 

What’s not normal

  • The baby refuses to eat
  • Fever over 100.4º F
  • Skin color changes
  • Excessive bleeding or foul-smelling odor from palate

For information on what to bring to the hospital for this surgery, see this post HERE. 

I hope you found this helpful. These are life-changing procedures for your little one, so while it may seem scary, it is so beneficial and helpful for them!

Thanks for visiting!

*photos courtesy of UCLA School of Dentistry
Orthognathic Surgery (Jaw Alignment)

Orthognathic Surgery (Jaw Alignment)

Posted on by The Cleft Dentist

 There was a special request to do a post on orthognathic surgery, or jaw alignment surgery, in cleft patients. So here we are! This can get pretty complicated, so I’m going to keep it as simple as possible! Let’s start with WHY this surgery is sometimes necessary for cleft patients.

It all started with the palate surgery…

The surgery that is done on the palate when the cleft patient is an infant leads to scar tissue forming on the upper jaw. Scar tissue is not as stretchy as normal tissue, so as the jaw tries to grow, the scar tissue pulls it back . At the same time, the lower jaw is growing normally. This leads to a discrepancy in size between the upper and lower jaws. 

Some say that a delayed approach to palatal closure significantly decreases the chance of the patient having to undergo this operation.

Also, the severity of the cleft determines whether or not this surgery will be done. This is mostly due to the fact that the more severe the cleft, the more surgeries there will be, leading to more scar tissue. 

The upper jaw ends up being smaller than the bottom jaw.

This is one of the reasons cleft patients need palatal expanders as part of their orthodontic treatment. 

Rapid Palatal Expander

What this looks like:

From the patient’s profile, the lower jaw is protruding out while the middle of the face looks sunken in. While the palatal expander helps to align the jaw from left to right, the jaw from front to back is still out of alignment. This is called an anterior crossbite, or Class III malocclusion. 

For some people, this can be fixed with braces, orthodontic rubber bands, and some tilting of the teeth. For others, the misalignment is too severe, and surgery is necessary. 

Why it’s important:

The dental malocclusion, or misalignment, can lead to speech and sleep obstruction issues.  It is also more difficult for the patient to eat with a misaligned jaw.

When it should be done:

The best time would be when the face is mature and before the patient finishes high school . This is between 14 to 16 in girls and 16 to 18 in boys. It is up to the patient and the doctors, though, when the surgery should be done.

It is preferable for the procedure to not be done until the secondary bone graft procedure is completed because there needs to be stability in the upper arch first. However, if a fistula remains, sometimes these procedures can be done at the same time. 

Let’s get into it, shall we? 

The procedure that is done is called a LeFort I osteotomy. The patient is being seen by the orthodontist at the time of surgery, who is responsible for creating an appliance that will guide the surgeon into the correct alignment of the jaws. The orthodontist knows how the bite should be, so the guide portrays how they would like the bite to be after the procedure. The guide is used by the oral surgeon during the operation to know where to place the jaw.

The upper jaw segment is separated during the surgery to allow it to be moved into the correct position. The incision is made right above the upper teeth. Bone is placed in the new space that is created. 

Le Fort I

Alternatively, there can be a device inserted into the upper jaw, and distraction can be done. What this means is the device will be adjusted,  and the maxilla will slowly go into place as the device is activated each time, moving bones apart. As the bone is “distracted” and moved forward into the right position, new bone forms, creating stability. This is usually done when the jaw discrepancy is more severe, and it takes about 6-8 weeks. The device is removed by the surgeon at this time. 

The main difference between the two procedures is that one is done slowly while the other is done in one surgery and one step. Also, with the distraction procedure, a bone graft is not necessary.

After the surgery

The jaw is  secured in place with metal plates and screws after the Le Fort I. A splint is used to hold the jaws in place for 6 weeks. You’ve probably heard of this as “jaws wired shut.” 

You will not be able to chew, so it’s important to make sure you get adequate nutrition through blended foods.

Try to aim for 2 or 3 nutrient-dense drinks per meal time. Avoid fizzy drinks, and try using a straw. That will help a lot. Good foods include milkshakes, smoothies, soups, juice, yogurt.

It is very important to use good oral hygiene still while healing. Use a small soft toothbrush to brush your teeth, and rinse your mouth with warm salt water.

After 6 weeks, start chewing slowly again. It will take a bit of time for it to feel normal again.

It will also be difficult to speak. Be patient, and bring a pen and paper with you everywhere! 

Complications

The side effects include:

  • numbness in the face
  • infection
  • instability of jaw
  • nasal blockage
  • loss of teeth
  • jaw returns to how it was before surgery
    • this is more common with Le Fort I

The most common side effect by far is experiencing temporary numbness in the face.  There are many nerves in this region of the face, so the surgery may affect some of those nerves. This is what causes the temporary numbness.

My story

I was lucky enough that I was part of the group of cleft patients who did not require orthognathic surgery. My Class III malocclusion (lower teeth in front of upper teeth) was corrected with braces and orthodontic rubber bands. My teeth were also tilted to be in front of my lower teeth.

I am so grateful for this, but I do remember when the orthodontist said “Let’s try to do this with just rubber bands, but if it doesn’t work, we will need to do jaw surgery.” Thankfully, I was diligent with my bands, and the surgery was not necessary.

I know this is one of the tougher surgeries for cleft patients, but the outcome is great and life-changing. 

Thanks for reading. Let me know if you have any questions!!

Packing for the Hospital

Packing for the Hospital

Posted on by The Cleft Dentist

A very popular question from parents is always: What should I bring to the hospital for my baby’s surgery?  

Great question!

You want your baby to be as comfortable as possible, and you want to be as comfortable as possible too! I know my mom always slept in the chair next to me each time I had surgery, and she always had a bag full of important things to make me feel better. 

*Side note>>for older children who have long hair, consider putting his or her hair in a braid since they are going to be laying on their backs for quite a while!

I want to address the 2 important surgeries early on in the baby’s life for this post.  I hope this can help you parents out there who are wondering what the heck to bring for this hospital visit!

I’ve included links and pictures of some amazon products I recommend. 

Let’s start with the Cleft Lip Repair surgery. 

Cleft Lip Repair Surgery- What to Bring

  1. Long sleeve t-shirt for baby that is slightly larger than normal
    • This will be for after the surgery> It will go under the “no-no’s”
    Click to Shop

  2. Favorite stuffed animal or blankie 
    • They might let your child hold this during the surgery!
  3. Sweatpants or leg warmers for baby to wear under gown

    Click to Shop
  4. Shirts should be zip up or snap up- NOTHING OVER THE HEAD (see above)
  5. Toys that can still be used with arm restraints on

    Click to Shop
  6. iPad for TV shows 
  7. A list of medications 
  8. The normal formula or breast milk you usually use & bottles
    • You may want to bring bottle washing supplies since you may be there for a couple of days
  9. Ziploc bags, wipes, antibacterial wipes, tissues 
  10. Bibs 
  11. Infant carrier and stroller
    • If you have a wrap, bring that too. Baby will want to be held after the surgery
  12. For you: 
    • Lots of snacks
    • Toiletries
    • Warm blanket
    • Sandals/Slippers
    • Dark clothing (because there will be blood from your baby’s drool)
    • Headache medicine
    • Phone charger
  13. Camera 

Cleft Palate Repair Surgery- What to Bring

  1. Shirts that are zip up or snap up
  2. Favorite stuffed animal or blankie
  3. Sweatpants or leg warmers to wear under the hospital gown
  4. Toys
  5. iPad for TV shows 
  6. List of Medications
  7. Squeeze pouches of applesauce, fruit, etc.
    Click to Shop

  8. Ziploc bags, wipes, antibacterial wipes, tissues
  9. Bibs 
  10. Infant carrier and stroller 
    • If you have a wrap, bring that too. Baby will want to be held after the surgery 
  11. Sippy cup that does not require suction

    Click to Shop
  12. For you:
    • Lots of snacks
    • Toiletries
    • Warm blanket
    • Sandals/Slippers
    • Dark clothing (because there will be blood from your baby’s drool)
    • Headache medicine
    • Phone charger
  13. Camera 

The most important thing…

Remember to take care of yourself, and bring necessities for you, too! Your baby will be doing lots of sleeping, so make sure you have something to entertain yourself. And definitely do not forget food for yourself! You will probably overpack, but as long as you have the things listed above, you should be great.

Don’t forget:

If you are calm, your baby will be calm too. 

 

I hope this helped! Feel free to comment below if anything in addition to this list was helpful for you.

Thank you, and good luck!

Cleft Lip Repair

Cleft Lip Repair

Posted on by The Cleft Dentist

Since we discussed the NAM appliance last week, it seemed appropriate to do this next post on cleft lip repair. It’s what comes after the NAM appliance is finished, which is around 3 months of age.

How a cleft lip forms

A cleft lip forms during the 6th week in utero due to failure of the lip fusing properly. During this time, facial structures are coming together in utero, and if that is interrupted, a cleft lip can occur. A cleft lip can be due to many reasons, some of which are discussed HERE.

It is actually the second most common embryonic deformity. It occurs in approximately 1 in 700 births. Cleft lip occurs more commonly in males, and a unilateral (cleft on one side) cleft lip occurs more commonly than bilateral cleft lips (occurring on both sides).

Unilateral
Bilateral

The cleft can either be a small, incomplete cleft, or it can extend into the floor of the nose and involve part of the upper jaw.

The lip needs to be repaired:

To prevent future problems with hearing, breathing, eating, speaking, and it also improves the patient’s physical appearance.

Most children are able to lead a healthy, happy life after cleft repair.

How has the NAM helped us get here?

The NAM appliance has reduced the size of the cleft, which will allow for a better esthetic outcome from the lip surgery. The surgeon doesn’t have to do as much “pulling” to connect the lip together.

Is it OK if we didn’t do the NAM, though?

Of course it is! The outcome will still be great. I didn’t have a NAM appliance when I was young, either.

The Surgery

At 3 months old, the baby will go under general anesthesia to have the cleft lip repair, so the baby will be completely asleep.  The baby will also receive local anesthetic after the general anesthesia has done its job in order to minimize bleeding and provide numbing to the surgical area.

The surgery usually takes between 2 and 6 hours, and the child will stay overnight for at least 1 day.

Young children usually get general anesthesia through a mask that covers the nose and mouth. A particular flavor can even be chosen for the scent. The good news is the baby will have no shots or needles while awake! An IV will be placed in the arm or leg to deliver medication only after the child is asleep.

The actual surgery requires an incision of one side of the cleft and then that skin is rotated to join the other part of the lip. The other part of the lip also has an incision to completely release it from underlying bone to allow the surgeon to move the lip to where he or she would like for it to go.

The baby will have stitches on the lip and base of the nose (depending on the type of cleft).

After the surgery

The child will wake up in the recovery room with an IV still in the arm or leg. Also, there will be a set of arm restraints called “no-no’s” to make sure the baby won’t bend his or her arms at the elbow and touch the face. These will need to stay on for 2 weeks.

Sometimes, nasal retainers will be used and placed in the nostrils to help shape the nose. These could stay in place for up to 3 months.

Nasal stents in place

The baby will stay in the hospital until the baby is able to drink fluids. The IV will then be removed, and the baby can go home! If any sutures need to be removed because they are not dissolvable, this will be done 1 week after the surgery.

Home Care

  • Only liquids until stitches are removed
  • Gentle cleansing of stitches with cotton swabs & diluted hydrogen peroxide
  • Gently massage area & avoid sunlight
  • No-no’s stay on for at least 2 weeks
    • remove them every 2-4 hours to make sure they are not too tight
  • Raise baby’s head slightly while sleeping to help with swelling
  • Clean the sutures after each time the baby eats
  • Vaseline can be placed on the stitches after cleaning
  • Most importantly: Remember that the baby crying will not harm the stitches!
What’s normal:
  • Bleeding from lip for up to 24 hours from surgery
  • Swelling
  • Difficulty feeding the baby
    • the baby needs to get used to his or her new mouth!
    • plus, there may be some soreness and swelling causing discomfort
  • Redness & firmness 4-6 weeks after surgery
What’s not normal:
  • Fever
  • Trouble breathing or skin color changes
  • Continuous bleeding or bad smell coming from stitches
  • Signs of dehydration
  • Movement of the nasal stents

My story

I didn’t have a NAM appliance when I was young because they didn’t exist yet!

I had my lip repair done when I was 3 months old. My parents kept my “no-no’s” for a really long time in the basement. I remember seeing them when I was about 10 and thinking they looked so small!!

My mom always told me it was very difficult to feed me after my lip repair. She said only 2 people were able to successfully feed me, which were my grandmother and her.  They would use medicine cups to drip fluids into my mouth. Imagine how tedious that must have been!

My lip repair was successful, and I went on to have many nose reconstructions, and when I was 21, I had a second lip reconstruction where my plastic surgeon was able to smooth over some of the scar tissue on the inside of my lip. It felt so amazing to not feel “bumps” on the inside of my lip.

I’ve never had any issues with my lip, and most patients don’t. After repair of the lip, patients can function normally in terms of anything to do with the lip. The challenging aspects are the palate, bone defect, and nasal defects.

Thanks so much for reading today. As always, let me know if you have a request for the next post!!

The Cleft Dentistâ„¢


http://www.surgeryencyclopedia.com/Ce-Fi/Cleft-Lip-Repair.html

http://www.chp.edu/our-services/plastic-surgery/patient-procedures/cleft-lip-repair

https://www.aboutkidshealth.ca/Article?contentid=33&language=English
*photos courtesy of UCLA
NAM Appliance

NAM Appliance

Posted on by The Cleft Dentist

We have a special post today because it is something that is very interesting to me for 2 reasons: 

  1. I never had the chance to experience a NAM appliance myself when I was a baby.
  2. I’m fascinated by the appliance, and I did a research paper on it in dental school!

Nowadays, it is very typical for a cleft baby to either have a NAM appliance or the Latham appliance prior to closure of the lip. While it is not absolutely necessary to have these appliances, it does help tremendously with the surgical result. In this post, we will be focusing on just the NAM appliance.

I will also be interviewing my husband towards the end of this post because he is currently working on a cleft baby, and he made a NAM appliance for the little one!  He is a maxillofacial prosthodontist fellow at UCLA.

What NAM stands for…

Nasoalveolar Molding

  • Naso= nose 
  • Alveolar= bone 

So literally, it means it helps to shape the nose and the segments of the palate on either side of the cleft (bone).

What it does

A cleft lip + palate creates a large defect in the lip and palate, often causing the nose to be off-center, especially in a unilateral cleft lip + palate. The reason for this is because due to the location of the cleft, there is no bone in the area to support the structure of the nose. Therefore, the bridge of the nose is pushed to the side.  In a bilateral cleft lip + palate, the nose may be centered, but it is often wide and flat.

NAM does not involve surgery! It is a device that helps shape the gums, lips, and nose in both unilateral and bilateral clefts. It gradually creates pressure to shape the facial structures and reduce the size of the cleft.  After that, the lip is surgically repaired.

The NAM appliance needs to be cleaned daily.  It is taken out of the mouth by the parent or caregiver and rinsed with toothpaste, toothbrush, and warm water before replacing the tapes.

Why it is so great! 

It usually requires the child to have less surgeries to repair the cleft than in the past. Reducing the size of the cleft with the NAM appliance allows for a thinner scar and helps the surgeon achieve a better shape of the nose. Quite often, the NAM can help prevent future surgeries that were once required for a cleft child. 

What it looks like

It is clear acrylic, and it looks like a retainer that fits over the entirety of the baby’s upper jaw.

NAM appliance

There is a button that comes out the front of the mouth where the cleft is through the lip.  Rubber bands are placed around the button on either side and pulled to create tension. Tape is then used to hold the appliance in place by taping the rubber bands to the cheeks. 

Button that rubber bands go around

When the cleft in the gums is reduced to about 1/4″, the nasal portion is added to the appliance. This is a projection that extends up into the nostril coming out of the front of the appliance and helps to remodel the nose from a flat shape to a more rounded shape. 

How it works 

  1. A dental impression is made of the newborn’s upper jaw by a dentist

    Impression
  2. The NAM appliance is made and inserted into the baby’s mouth
  3. The rubber bands are applied, and tape is placed on the baby’s cheeks
    • This creates pressure upward and backward. It is perfectly NORMAL for the eyes to droop down and the skin to be irritated by the tape. The eyes will return to normal once NAM is finished, and the doctor actually uses the skin irritation as an indication that you are correctly using the appliance at all times!
    • Tape is replaced daily by the parent
    • If the appliance is not sturdy in the mouth, replace the tape and pull more tension on the rubber bands 

      Tape & Rubber Bands around knob
  4. Adjustments are made to the NAM on a weekly basis by adding to the acrylic on the inside surface
    • Each time the baby comes in, more material is added to the area of the cleft to continue creating pressure. The pressure helps to redirect the growth of the face and palate as the child grows. Each adjustment is very small. 
  5. When the cleft is reduced to about 1/4″, the nasal portion is added to shape the nose
    Nasal Portion in nose

    Nasal Portion added
  6. By the time the baby is ready for surgery, the cleft has been reduced significantly, which makes for easier surgical repair 

Benefits 

  • Helps to create suction by closing the cleft while appliance is in place (easier for feeding)

  • Weekly checkups are always nice to have to make sure the baby is progressing well!
  • Speech will be much better due to smaller cleft
  • Minimal scarring
  • More rounded nose
  • Fewer future surgeries 

Interview with Dr. Paul Canallatos

At what age does the NAM appliance start?

It is ideal to start within the first 6 weeks of life.

Does the baby need to wear the appliance all the time?

The baby should wear the prosthesis at all times, including feeding. It can be removed temporarily for hygiene, but it is ideal to have it worn as much as possible to allow the molding to take place.

Does it hurt the baby?

It does not hurt the baby, but it is uncomfortable for a couple of days after an adjustment is made- much like a patient is sore after getting an adjustment at the orthodontist.

How does the baby eat with the appliance in?

The baby is able to be fed via a bottle the same way as without the prosthesis. The baby can sometimes even eat better with the prosthesis in after a while.

How long does the baby need to wear the appliance before surgery?

It is ideal to have the prosthesis worn up until the 3-month period before the first surgery, which is the lip surgery.

How do you make the impression of the baby’s mouth?

The impression is made with a putty material that is very viscous so the patient will not breathe in the material. While making an impression, we make sure there is plenty of room for the baby to breathe. The patient cries during the impression because it is something new, but it does not hurt. Crying is a good thing because we know we have a clean airway then!

Let us know if you have any other questions!

 *pictures provided by UCLA
Frequently Asked Questions: dental-related

Frequently Asked Questions: dental-related

Posted on by The Cleft Dentist

You guys asked some great questions!   The questions I received were all dental questions, so I will be doing another post on non-dental FAQs as well! I did my best here to answer your questions, especially the ones that were asked the most. I’ll be happy to add to this post if any other questions come up as you’re browsing.

This blog is completely for you guys, so I hope these answers help! Let’s dive in!

My son’s adult front tooth grew in sideways. When and how will that get fixed?

This is actually pretty common in cleft patients for the teeth to grow in sideways next to the cleft. The reason for this is that teeth like to migrate and grow towards SPACE. Wherever there is room, the teeth tend to go. Most of the time, this will happen when the corresponding baby tooth is still in the mouth. The adult tooth will grow toward the space of the cleft because it can sense there is room for it to grow! The tooth will be fixed during orthodontia. Braces will move the teeth into their proper positions around the age of 11-14. This is done after the bone graft procedure.

My daughter is 1 month old. How many teeth can I expect in the coming months?

4-7 months: The first teeth will most likely be the two lower front teeth, but teeth can also begin appearing around 3 months old.

8-12 months: The front top teeth will appear around this time. In cleft patients, both front top teeth may not erupt due to the cleft being in this area. That is normal.

9-16 months: Next, the front top teeth next to the central incisors will erupt. Again, in cleft patients, this may not erupt because there is no bone in this area. That is also normal. Next, the lower lateral incisors will erupt (the teeth next to the central incisors).

13-19 months: The molars will erupt.

16-23 months: Canines will erupt.

23-33 months: Second molars will erupt.

Do not worry too much if the teeth do not arrive during these time frames. Especially with cleft patients, there can be delayed eruption of the teeth. The teeth will erupt when they are ready!

What is the average lifespan of dental implants? Do you usually have to get them redone?

Dental implants can last decades if you take good care of them. They are always placed with the intent of having them last even your lifetime. The best way to take care of them is to make sure you are flossing around them, and also, I highly recommend a Waterpik.  The implants do not normally need to be replaced unless an infection develops around them, bone loss, or periodontal disease affects them. What is more likely to occur is that as you get older, you will notice the teeth with implants on them will appear shorter than the teeth next to them. This is because your face grows, but the implants stay in one spot. If this is bothersome to you, only the crown will need to be replaced…not the implant!

My baby has a gum notch. What procedures could be involved?

I’m assuming that by “gum notch” you mean a defect in the bone where the cleft is. Possible procedures include bone grafting, orthodontics, and others, depending on the type of cleft your child has. A good post to look at is the Timeline of Events one.  This should help!

Does having a gum notch mean her teeth will become rotten?

No! Having a cleft does not predispose patients to having rotten teeth. Having a cleft merely means there will be some difficulties with teeth, such as later eruption or no eruption at all in the area of the cleft. This does not mean cleft patients will definitely lose teeth. Most cleft patients just don’t have their front adult teeth, and THESE options can be explored if that is the case. As long as you take care of your teeth, you will not lose them!

My 3-year-old son has a transparent spot on his front tooth. Is there anything I can do for his future teeth?

This sounds to me like it is just a thin spot of enamel. If it’s just one spot, it does not sound alarming. Sometimes, there can be the opposite effect where there is a white spot. These spots are not worrisome at all. The enamel is weaker in these areas, so just keep an eye on these for any appearance of a cavity. As for the future teeth, this can happen in any of those teeth as well and are not related to the baby teeth. It may happen in the adult teeth, or it may not happen, but there is no way to prevent it. Just make sure to do proper hygiene to reduce the risk of cavities!

Are clefts associated with weak tooth enamel or something that would predispose to decay? Should I be concerned about his adult teeth?

Clefts are not associated with weak tooth enamel. One interesting characteristic of cleft patients though is that we are mouth breathers much of the time because we do not breathe well through our noses. This can create a dry environment in the mouth, which can lead to decay. This is because saliva has certain elements in it that protect the teeth from harmful bacteria. The way to prevent decay is proper hygiene and also drinking water to keep the mouth salivating will help!

 My baby has gum notch. What is the procedure for the gum notch?

Again, I’m assuming here the gum notch means a defect in the bone where the cleft is. This area will remain as is until about the age of 10, when the fistula is finally closed with the bone graft. I explain all about the bone graft in THIS POST.

Will babies with clefts suffer with teething?

Yes! Just like any other baby, though. That part is completely normal.

Some skin on the upper lip is joined with the gum notch on my baby. How will it be normal?

This sounds like the frenulum attachment. This is just a muscle attachment that occurs in people without clefts too. It is not a bad thing, but it could pull on the muscle between the 2 front teeth if not removed, leading to a space between the two front teeth. It can be cut at any age, if you would like.

Will having a cleft of the soft palate only cause any tooth problems?

Usually there are no tooth problems with clefts of the soft palate. The only tooth problems are the ones that those without cleft palate would experience!

Does having a cleft lip & palate mean they will need a palate expander down the road?

Usually, a palatal expander is a good idea because due to the surgeries of the palate, the scar tissue pulls on the teeth and jaw and constricts the upper jaw. The constriction causes an inaccuracy in the bite of the cleft patient. An expander will help expand the palate to achieve more space in the arch to make up for the constriction that has occurred.

My cleft child has a tooth coming through her palate. Will this cause any issues with her palate repair?

This is actually very common in cleft patients. It would only cause an issue with palate repair if it is in the way of where tissue in the palate will be taken to do the repair. Usually, the tooth will be extracted at time of palate repair, especially if it is so far from the rest of the teeth that there is no way orthodontia could fix it.

Where can I find an orthodontist for my cleft child? 

Search for “craniofacial orthodontist” in your area!

What is your take on snap-in dentures, and are there any problems with them?

Snap-in dentures are absolutely wonderful. They are actually considered the gold standard for dentures on the lower jaw. Two implants are sufficient for snapping in the denture, and they help to hold the denture in one spot! This is especially helpful if you don’t have much bone in the lower jaw from wearing dentures for so long. The dentist just needs to make sure you have enough bone for implant placement! Snap-in dentures are not necessary in the upper jaw, unless there is some abnormality in the maxilla. The most common complication with these dentures are that the little buttons on the inside of the denture where the implants snap in actually wear over time, so they need to be replaced. Another common complication is the denture may break in half between the two snaps. These complications are nothing though compared to how your life will be changed for the better!

Is it common to miss other teeth not in cleft areas?

Yes, but this is unrelated to the cleft. People will commonly miss lateral incisors or premolars.

Is it common to have a frenulum connecting a cleft child’s upper lip to the gums in the area of the cleft?

This is also not cleft related, but can happen in cleft patients as often as it does in non-cleft patients. Please refer to question above regarding frenulum!

Does an expander cause a fistula in the cleft area?

No! The upper jaw in a cleft patient is usually constricted because of scar tissue pulling on the jaw from previous surgeries. This constriction will make the fistula appear smaller. As the palate is expanded, the fistula will appear larger. An expander just draws more attention to a fistula that was already there!  Also, a fistula is left in the cleft area until the bone grafting procedure is done, which is usually right after palatal expansion.

How many hours in dental school are spent learning about cleft-related issues? What is the knowledge-base of an average dentist regarding clefts?

Honestly, not much. We learn about what it involves and how it develops in the womb. We don’t learn about specifics in treating cleft patients. So, an average general dentist knows what a cleft lip & palate is, knows which teeth are affected, and in general, knows what steps need to be done to repair the cleft. However, specialists, including oral surgeons, orthodontists, pediatric dentists, and prosthodontists, all have a strong knowledge-base regarding clefts. We treat these patients during our residencies as well, so we know how to deal with cleft patients in detail. A  toddler will be treated by oral surgeons, pediatric dentists, and a maxillofacial prosthodontist. Young children will be treated by oral surgeons, pediatric dentists, and an orthodontist. Adults will be treated by a prosthodontist, oral surgeon, and a general dentist can also treat an adult with a cleft.

 

That was fun!  Thank you so much for submitting your questions! Please feel free to submit follow-up questions in the comments section, below.

 

Options to Replace Missing Teeth

Options to Replace Missing Teeth

Posted on by The Cleft Dentist

You want to smile?

Without feeling self-conscious. Without having to put your hand in front of your mouth when you laugh. Without people staring. Without hesitation.

I totally get it.

Luckily, there are options for cleft patients, and luckily, this is my specialty!

Replacement of missing teeth for prosthodontists is the name of the game. The entire reason I became a prosthodontist is because replacement of my missing teeth literally changed my life.

Most cleft patients are either missing 1 or 2 teeth in the area where the cleft is. So, the teeth we are talking about here are the front tooth and the tooth right beside that one. Most often, the tooth beside the front tooth is the one that is missing. It depends on the size of the patient’s cleft. Also, this may just be on one side or both sides, depending on if the cleft is unilateral or bilateral.

The most important aspect of replacing missing teeth:

Is definitely making sure it is well treatment planned and involves the dental specialties, including:

  • Oral surgeons-perform surgery on teeth, including extractions
  • Orthodontists- align improperly placed teeth
  • Prosthodontists– replace missing teeth in many ways (which we will discuss below)

Coordination among all specialists is of the utmost importance to achieve the best result. For example, if the prosthodontist needs more space for  replacement of teeth, but the orthodontist has already removed your braces, would you really want to get back into those braces? 

Neither would I.

So what are the options?

Let’s dive into it. I’ll outline the options for you, and you will need to discuss with your dentist which option would be the best for you. Of course, I would highly recommend you seeing a prosthodontist, because this is a prosthodontist’s specialty.

Orthodontic Treatment

The majority of cleft patients require orthodontic treatment to align the teeth. When there is a missing tooth, the teeth that are present tend to shift into the area of the missing tooth. Teeth LOVE moving to where there is space. This isn’t just in cleft patients. It happens in all patients, in all areas of the mouth.

Braces will help to straighten out the teeth and align the jaws. They will also help move the teeth to allow for space. The space must be maintained for when replacement of the missing tooth will occur.

During orthodontic treatment, once space is made, fake teeth can be attached to the wire to temporarily replace the missing teeth. This is a great option for patients.

Once braces are removed, a retainer is made for the patient to wear to maintain the teeth in their positions, and fake teeth can be attached to the retainer as well.

Wait, there’s more!

Also, with orthodontics, sometimes, if the patient is only missing one tooth, the space can be closed with braces. What happens in this situation is the canine is brought into the lateral incisor space and shaped to look like a front tooth.

It is up to the orthodontist and the prosthodontist which direction to take. And, of course, it is up to you, the patient, too!!

Removable Partial Denture

This is a good option if the patient does not have grafted bone. The benefit of removable partials dentures is that it is the least invasive method of having missing teeth replaced. Very minimal preparations are done to the existing teeth in order to have a framework seamlessly rest on the teeth. For strength, stability, and support, the removable partial denture will need to cover most of the palate and will  clasp around the teeth to hold the partial in place.

Another downside is that it is removable, but this is a great last resort option and is also the most inexpensive option.

The framework is in metal, and the teeth will be surrounded by pink acrylic, which simulates the tissues in your mouth.

This option can also be used as a temporary option or an option to use while saving money or time until a finalized treatment is decided upon.

Fixed Partial Denture

This is another good option for a patient with non-grafted bone. The benefit of fixed partial dentures is that it is not removable and feels more natural than a removable partial denture.

The largest disadvantage is that the teeth next to the site of the missing tooth or teeth need to be drilled down in order to put crowns on them. The fake tooth, or teeth, is connected to the crowns next to it, forming a bridge.

Another disadvantage is that it is more difficult to clean because you cannot floss like you normally can with your other teeth.

If you do decide on this treatment option, definitely make sure you either get a Waterpik or Floss Threaders in order to appropriately clean around this area. It’s very important to keep this clean to avoid cavities on the supporting teeth. If a cavity does form, the whole bridge would need to be cut off, and a new one would need to be made.
Waterpik & Floss Threader

We usually do not prefer doing a bridge, especially in a younger person, unless the teeth next to the missing teeth have many fillings or are broken down already.

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This option is a good option if you are able to keep your teeth clean and if you can afford spending a little bit more money on the treatment plan. This option is also a great backup option for if you were planning on having implants done, but the implants have failed and no further surgeries are indicated.

Resin-bonded fixed bridge

To avoid drilling out the teeth next to the missing tooth, a resin-bonded fixed bridge, or a Maryland bridge, is a great option. A fake tooth is connected to a wing that is attached to the back of the tooth or teeth next to the missing tooth.

This can really only be used if only one tooth is missing per side though, because it is not very strong.

The major disadvantage to these is they de-bond frequently because they are only bonded to the back of the tooth next to the missing tooth site. There is minimal tooth preparation on the teeth next to the site. In some cases, this can be used as a permanent option, but most of the time, it is used as temporary option until the patient is old enough for dental implants.

The advantage is the minimal tooth preparation, and the fact that it is fixed in the mouth.

To be eligible for a resin-bonded fixed bridge, the most important thing to consider is the bite. There needs to be enough space behind the front top teeth to have space for the wings to be bonded. Usually, in cleft patients, this is not a problem because most cleft patients bite with their teeth edge-to-edge rather than having the bottom teeth behind the top teeth. Your prosthodontist will make the final decision.

Still, with this option, you are not able to floss as normal so a Waterpik or Floss Threaders are indicated (see above to purchase).

Dental Implants

Dental implants can only be done in grafted bone. There are many benefits to grafted bone, as shown in my previous post that you can find HERE. There needs to be enough bone to accommodate implants. This can be seen through a CBCT, which is a 3D image of the bone.

Dental implants feel the most natural because you are able to floss around them just like normal teeth. The details regarding dental implants can be found HERE.

This involves a screw that simulates the root of a tooth being drilled into the bone. After about 2 months, a crown can be attached to the implant. This treatment option does require surgery, but the healing is NOTHING compared to what cleft patients have been through with other procedures. The cleft patient will feel completely normal as soon as a few hours after dental implant placement. While the bone is forming around the implants, the patient needs to make sure the area is clean by using chlorhexidine (prescribed by your doctor) and also brushing the teeth as normal.

Avoid trauma to the area as well because the bone needs to be sturdy and healthy to integrate with the implant.

The most advantageous part of dental implants is that teeth next to the site do not need to be disturbed at all. No drilling or modifications are necessary. Healthy teeth will remain healthy!

This is the most expensive option, however. Some insurances will cover the cost for cleft patients though because it is considered medical. Never hurts to try!

My story

For most of my childhood, I had a large space where I am missing my front central tooth and the tooth next to it.

Finally, when I had braces, my orthodontist made space and attached 2 teeth to my orthodontic wire so I could finally smile without feeling self-conscious.

After my braces were off, I wore a retainer for about 3 years before finally getting a flipper. I did not know I could have had a flipper during this time. Make sure you ask your dentist!

I did end up getting dental implants, which failed after 10 years. I absolutely loved my implants. I had never felt so normal and confident in my smile! Currently, I am healing from my 4th bone graft surgery, and I had dental implants placed just 2 weeks ago! I am wearing a flipper in the mean time and also an orthodontic retainer at night time to maintain my tooth positions.

Implants- picture taken an hour after surgery

In a few months, I will be able to have crowns placed on my implants, and I simply cannot wait! In the mean time, I’m making sure I eat plenty of protein and keep the area clean.

Please comment below, and tell me your story regarding your missing teeth! 

Can’t wait to read your responses.

 

What I Ate: the post-surgical soft food diet

What I Ate: the post-surgical soft food diet

Posted on by The Cleft Dentist

It is so important to make sure you have a well-balance diet, even though it may seem so limited with soft foods. You'll see how easy it is to get creative with what you can eat! It is ESSENTIAL to increase your protein intake to help with tissue healing.

Wednesday, March 28th

Day of Surgery

 

Post-surgery:                    

Image result for pressed juicery freeze chocolate & vanilla swirl

Pressed Juicery ice cream:

Vanilla Almond & Chocolate Almond- made of only almonds, dates, vanilla, and sea salt

 

Snack:

Mug Cake

Chocolate Mug Cake:

  • 1 scoop Protein Powder
  • 1 tbsp coconut flour
  • splash vanilla extract
  • 1/4 tsp baking powder
  • 1/4 cup milk (any you like)

You can either microwave this for 1 minute or eat as is. I like to eat as is. It tastes like cake batter!

 

Dinner:

Crockpot Sweet Potato Lentils

Crockpot Sweet Potato Lentils:  Serves 6

  • 3 large sweet potatoes
  • 3 cups vegetable broth
  • 1 onion, minced
  • 2 tsp coriander, 2 tsp garam masala, 2 tsp chili powder
  • 1/2 tsp salt
  • 1.5 cups uncooked red lentils
  • 2 cups milk (any you like)
  • 1 cup water

Cook on LOW for 6 hours. This is great for the day of surgery, so you can just throw it all in a crockpot and not worry about it for later!

 

Thursday, March 29th

Day after surgery

 

Breakfast:

Rebbl

Rebbl Turmeric Golden- Milk:

Turmeric is great to have post-surgery because it helps with INFLAMMATION. I added some protein powder to this to make sure it was well-balanced.

You can buy this at Whole Foods or on Amazon.

 

Snack:

Mug Cake

Chocolate Mug Cake: recipe can be found above

 

Lunch:

Smoothie Bowl

Green Smoothie Bowl:

  • 1 cup spinach
  • 1 scoop protein powder
  • 1/2 frozen banana
  • 1 tbsp. peanut butter
  • 1/2 cup strawberries

Topped with: 1 tsp honey, 1 tsp tahini

Blend altogether!

 I like smoothie bowls because it feels more substantial than just drinking a smoothie. Plus, remember, no straws during this time! It's perfect to top it off with soft foods, and then it feels more like a meal.

Snack:

Banana Bread

Soft Banana Bread*:

  • 3 medium ripe bananas
  • 1/2 cup creamy almond butter
  • 2 eggs
  • 1 tbsp. honey
  • splash vanilla extract
  • 1/3 cup coconut flour
  • 1/2 tsp baking powder
  • sprinkle cinnamon

Bake at 350º for 30-40 minutes. Topped with honey and creamy peanut butter.

*Recipe from Rachl Mansfield

 This bread is seriously so soft and delicious. Be careful with your toppings and make sure they are smooth and soft enough to do minimal chewing and easy to swallow.

Dinner:

Roasted Red Pepper Soup

 

Creamy Roasted Red Pepper Soup:

Recipe can be found HERE

You already know how I feel about this recipe. It's SO good. It's also surprisingly filling, so one bowl of this one, and you are set! Make sure you give it a good blend so there are no surprises when you're eating.

Hope you got some new ideas!

I just wanted to show 2 days of a soft food diet. You can get really creative with it! If you do not want to use protein powder, or the child is too young for the protein powder, I would suggest using yogurt, oats, hemp seeds, or flax seeds as a substitution.

Feel free to leave me a comment below with any questions you have or any other suggestions you'd like to know for some soft-food recipes. I have many more! I'll be posting them periodically in the Recipes section of the blog.

Also, healing has been going well! I'm still sticking to a soft-food diet to not disturb the implants. I'm also taking Osteoven supplements to help with bone formation!

What do you want to know about next? Visit my Requests page, and drop me a comment!