Tooth related anomalies include abnormalities in the size, shape, location and eruption of teeth. Both deciduous and permanent teeth are involved. The affected lateral incisor occurs on the distal side of the cleft. The tooth can also be missing or divided into two. Central and lateral incisors adjacent to the cleft can be peg shaped (very small) and have poor enamel (hypoplasia). With small or missing upper lateral incisors, the decision must be made whether to close spaces or open spaces for prosthodontic replacement (prosthodontic referring to false teeth which may be an implant where a metal structure imitating a tooth root is placed in the bone). The usual evaluations of arch length deficiency in both arches are made and the level of crowding or spacing will determine the best approach, also keeping in mind the comments regarding the avoidance of excessive Class III (where the lower jaw projects forward of the upper jaw; can be a small upper jaw, large lower jaw or a combination of both) camouflage below. However, the current alveolar grafts do mean space closure is a more realistic objective (alveolar bone is the bone in which the teeth are contained). Where space dictates a prosthodontic option, an implant can also be used with reasonable success. A supplemental bone graft may be required.

Comprehensive orthodontic therapy with full fixed appliances can be undertaken in the late teens. Due to the Class III pattern, treatment is must often be undertaken following the adolescent growth spurt. The restriction of forward maxillary growth means even greater than usual consideration must be given to the possibility of mandibular growth re-establishing the Class III pattern. Treatment for a significant Class III pattern involves a combined orthognathic-orthodontic approach; camouflage should be avoided in these cases. Estimates of the number of patients requiring orthognathic-orthodontic treatment range from about 10% in some centres to 25 % in others. A feature is the maxillary hypoplasia (small upper aw). Restriction of maxillary growth results from surgical ankylosis, where the scars of the earlier required surgery limit forward maxillary development. Mandibular prognathism (large mandible = lower jaw) can be present in cleft cases just as in non-cleft cases; retrognathia (small lower jaw) can also be present. Bimaxillary (both jaws, maxilla and mandible) surgery with mandibular setback may be required in cases without mandibular excess due to the extent of the sagittal discrepancy. Overcorrection provides a margin for some relapse. A surgically repaired upper lip results in a limiting soft tissue barrier to the dentition. The ability to procline maxillary incisors is reduced. The temptation to compensate by keeping the upper dentition forward and simply extracting lower premolars and retracting the lower incisors should be avoided in most instances. A far superior result in these more pronounced Class III cases can usually be obtained with orthognathic surgery (jaw surgery). Due to missing teeth, osseointegrated implants may also be indicated, and if inadequate bone is present, then a supplemental bone graft may be required.

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