can lead to cross-bite and mid-line deviation, as well as asymmetrical jaw movements
and tenderness and pain from muscles and joints. Congenital aplasia of the TMJ may
occur in syndromes such as hemifacial microsomia and Treacher-Collins syndrome,
and results in abnormal growth and function. Such cases require a combined
interdisciplinary approach.
14.10 CLEFT LIP AND PALATE
Patients with clefts of the lip and palate commonly need extensive and specialized
treatment, provided by a multidisciplinary team of specialists including plastic
surgeon, orthodontist, paediatric dentist, speech therapist, maxillofacial surgeon, ENT
surgeon, and others. Approaches to management vary greatly. It is not the purpose of
this section to discuss the details of the condition or its treatment, for which the reader
is referred to specialist texts, but rather to highlight the crucial part the dentist plays in
maintaining dental health throughout the prolonged period over which the treatment
usually extends.
Management begins at birth with counselling of the parents to reassure them, explain
the likely course of events, and to give practical advice on feeding. Sometimes
presurgical intraoral appliances are fitted to try to reduce the size of the defect and
facilitate surgical repair. The lip is repaired within the first few weeks or months,
followed later by closure of the palate. The primary repairs are followed by a period
of observation, usually in multidisciplinary clinics attended by the various specialists.
As well as observing facial development, speech is monitored and corrective
measures, such as speech therapy or palatopharyngeal surgery, instituted where
necessary. These children often suffer middle ear infections for which ENT advice
will be needed. As with all children, advice on preventive dental care should be given
to the family and reinforced regularly.
A complication of surgical repair is that scar contraction in the palate causes
narrowing of the upper arch. Sometimes this is quite dramatic, although modern
techniques are reducing the severity of this problem. Orthodontic treatment often
begins during the mixed dentition stage, at about 8 or 9 years, with expansion of the
upper arch in preparation for a bone graft into the alveolar defect at about the age of
10 years. Grafting at this age provides bone into which teeth can erupt, particularly
the adjacent canine, and greatly aids occlusal development. Clefts are often associated
with other dental anomalies such as supernumerary, microdont, or impacted teeth.
Further orthodontic treatment, normally with fixed appliances, is needed when the
permanent dentition has erupted⎯if this includes significant arch expansion, the
patient will have to wear an appliance permanently to prevent relapse of the
expansion. Secondary surgery to the lip and palate repairs may be needed. If scarring
has restricted forward growth of the maxilla, surgical correction of a class III facial
deformity may be considered in the late teenage years after growth is complete. This
usually requires orthodontic preparation to give a satisfactory postoperative occlusion.
Finally, restorative treatment may be needed because of missing teeth or other defects,
and often to provide permanent retention of the orthodontic tooth movement.
It is obvious that the success of all this treatment depends on the maintenance of a
sound dentition over many years, and that the loss of teeth due to caries greatly