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.
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.
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!Â
Can’t wait to read your responses. 