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PROSTHETIC REHABILITATION OF CLEFT PALATE PATIENTS Introduction The cleft lip and palate deformity is a congenital defect of the middle third of the face, consisting of fissures of the upper lip and or palate. The patient with clefts of the primary and secondary palate presents a complex biologic, sociologic ,and psychologic problems. For the effective treatment of the cleft palate patients, there should be coordinating efforts of numerous specialists from the medical, dental and speech pathology departments. Prosthetic need will vary with each patient from presurgical orthopedic appliances,speech aids,single tooth replacements,multiple tooth replacements,complete dentures with speech aid and prosthetic replacement of the missing facial units. CLEFT PALATE
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The cleft lip and palate deformity is a congenital defect of the middle third

of the face, consisting of fissures of the upper lip and or palate. The patient with

clefts of the primary and secondary palate presents a complex biologic, sociologic

,and psychologic problems.

For the effective treatment of the cleft palate patients, there

should be coordinating efforts of numerous specialists from the medical, dental

and speech pathology departments.

Prosthetic need will vary with each patient from presurgical

orthopedic appliances,speech aids,single tooth replacements,multiple tooth

replacements,complete dentures with speech aid and prosthetic replacement of the

missing facial units.


Is defined as a congenital fissure or elongated opening in the soft and\or hard



An opening in hard and/or soft palate due to improper union of the

maxillary process and median nasal process during the second month of intra

uterine development.

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drugs{phenytoin,barbiturates etc} in first trimester of pregnancy

poor diet

hormonal imbalance


-Based on the extent of the defect

Class I :- cleft lip with cleft alveolus (primary palate)

Cass II:- cleft of hard and soft palate (secondary palate)class II :- combination of

class I and classII

Veau’s classification(1922)

Class I cleft involves only the soft palate

Class II :- involve the soft and hard palate but not the alveolus.

Class III :- which involves the soft and the hard palate continuing through the

alveolus on one side at pre maxillar area.

Class IV :-which involves the soft and the hard palates, the cleft continuing through

the alveolus on both sides ,leaving a free premaxilla.

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1. Feeding problem in infancy due to oronasal communication

Lack of negative pressure necessary for suckling .

Nasal regurgitation of food

Feeding time is significantly longer and fatigues both baby and parent

2. Defective speech : Inadequate palate function causes

Defective speech & hypernasality

Patient may recruit abnormal facial and pharcyngeal muscle for speech .

Atypical movement pattern of tongue, lips and mandible .

3. Abnormal swallowing patterns :

Inadequate separation between the oral and nasal cavities inorder to prevent

nasal regurgitation .

4. Recurrent middle ear infections : Due to veloopharayngeal deficiency , middle

ear infections are common in cleft palate patients.

5. Abnormal tongue & Jaw – position : Medial –position of the maxillary

segments forces the tongue and jaw to assume a lower position . Abnormal position

of the tongue below the teeth stops the vertical development of the maxilla by

interfering with normal tooth eruption . There will be compensatory eruption of

the mandibular teeth which increases the vertical development and produces an

occlusion at highest level than is desirable for aesthetic facial proportions.

6. Protruded pre-maxilla :- seen in bilateral cleft cases . Lip closure is often difficult

7. Associated facial defects : Such as nasal deformity , ear deformity , facial cleft,

mid-facial retrusion etc.

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9. Dental problems include constricted upper arch and crosstie, missing teeth

(Commonly lateral incisor ) supernumerary teeth closed bite, severe malocclusion .

10. Socio- psychological, problems : Most patients will have psychological trauma

due to poor speech and aesthetics so treatment should also address psychological

needs of patients also .

Team approach

Cleft palate patients presents with a complex biologic, sociologic, and psychologic


Best management involves several disciplines, a team approach. Members include.


Plastic Surgeon



Speech pathologist



Pediatric psychiatrist and social worker .

Diagnosis in cleft palate treatment

It in based on the assessment of findings on morphology – and function

Treatment of cleft plate patients

History :- Bein suggested that first otruration of a cleft palate was by

Demosthiscus(384-323 B.C),great Greek Orator, who used to visit seashore in

search of properly sized pebbles to till his palatal defect thereby improve his speech.

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More current medical literature credits, Stollerius, Petronius and Pare with

descriptions of prosthesis for obturation of palatal defects in 16 th century. Works by

snell, stearn, kingsley and sareson in 19th century describe current prosthetic


Clinical observation evaluated according to the expected morphology,

function & consideration for future growth potential.

Methods of Morphological assessment

Clinical examination of lip, tongue and jaw position during rest .

The movement of mandible from rest position to maximum inter cuspation of teeth.

Is observed forward shift with overclosure of the mandible can be noted.

Problems of speech :- evaluated by speech pathologist can distinguish errors in

language development , articulation, nasal emission ad resonance balance .

Principles of treatment

It may be useful to identify some of the characteristic of cleft palate patients at

various ages and identify which factors support a favourable prognosis .


Suckling & swallowing problems : prevented by ,

A more upright position of infant a bottle with the nipple opening slightly

enlarged .

Gastric tube feeding is sometimes necessary .

A small palatal prosthesis ; feeding plate ca be given

In Pierre Robin syndrome (with small tongue & mandible with cleft) small

tongues can fall back and block the air way.

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A palatal prosthesis that covers the cleft and us extended downward to keep the

tongue and jaw forward, is given.

Primary lip surgery : is done within the first few months after birth when the

infant is thriving .

Lip closure without excessive tension provides, favorable, contour un the

pre-maxillary area and narrows the cleft of the patient .

In Bilateral clefts, the traction to facilitate lip closure in clone with various

appliances .

After lip closure has been achieved, the position of maxillary segments will

move under the influence of the established tension.

The pre positioned segments can be maintained

Retention appliances & intra alveolar bone grafting procedures .

Primary palate closure:-

Timing varies from about 18 months to 4 years. Sometimes delayed in wide

clefts with lack of available tissue.

In this case an interim prosthesis can be given. But the decision is made on an

individual basis.

Primary Dentition

In bilateral cleft, premaxilla is prominent at this age.

Main concern is to prevent maxillary incisors from resting infront of the lower


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In some cases extraction of malpositioned incisors and allowing some

resorption of alveolar process may be necessary.

Lateral incisors may be located in the cleft . These malpositioned teeth should

be preserved because they offer support to counteract forces moving the cleft

maxillary segment in a media direction.

A palatal fistulae that is sufficiently large to allow fluid loss through the nose

or contribute to nasal air escape in speech can be obturated by a simple palatal


Mixed Dentition

Eruption of central incisors into a normal over bite relationship to mandibular

teeth is critical.

An edge to edge bite at this time can lead to development of a forward shift and

over closure of the mandible.

Judicious grinding of teeth can be done to establish normal relationship of the

anterior teeth.

Most common missing tooth is lateral incisors when the cleft affects alveolus

supernumerary teeth are extracted if they are not contributing to the bone

development in the alveolar process and are of no use for prosthodontic


Reduced number of teeth in mandible in bicuspid areas may be an advantage in

cleft palate treatment.

But if maxillary bicuspids are missing, it will complicate upper arch size.

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In this case maxillary molars are moved forward and the size of the mandibular

arch should be reduced by extractions if necessary.

Rotation of the maxillary bony segment laterally especially in the anterior part

of maxilla is achieved with orthodontic appliances .

Retention is usually accomplished by use of lingual arch wire.

Additional movement of cleft segment may be required to keep up with

mandibular growth.

Replacement of lateral incisor can be done by cold curing a plastic tooth onto

lingual arch wire.

Speech and hearing evaluations and surgical revision of the nose, lip and palate

are done depending on the needs of individual patients.


The Orthodontic Treatment at adolescence is designed to achieve

Normal position of the maxillary segments

Adequate vertical development of maxilla and

Alignment of teeth for efficient occlusion, aesthetics and positioning to permit

conservative, prosthodontic replacement of missing teeth.

Consultation between orthodontist and prothodontist is necessary. Additional

adjustments of anterior tooth position may be required at about 18 years of age.

After the maxillary segments and canines are brought into maximum favourable

position, permanent stabilization of the arch by establishment of bony continuity

between the cleft segments can be safely accomplished at 14-16 years.

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Various bone graft procedures are available for stabilization of maxillary

segments and support for nasal alae.

This stabilization of maxillary segment by healing the cleft through new bone

formation allow the prosthodontist to reduce the span of fixed prosthesis,

replacing missing teeth.

Without an intact maxilla a fixed prosthesis, must extend at least two teeth an

either side of the cleft to resist relapse tendencies.

Fixed prosthetic restorations are usually constructed at 20 years of age. By this

time, no further adjustment in tooth position required and sufficient tooth

structure can be removed in preparation for full crown coverage to provide

necessary parallelism and gingival extension for retention and aesthetics.


Prosthodontist will see patients who have not received optimum treatment and

there are still who may require removable partial prosthesis to camoflage the

collapsed maxillary segments and reduced vertical development of maxilla.

Design of these prosthesis is further complicated when a pharyngeal obturator is

incorporated to aid speech.

The edentulous cleft palate patient represents a failure in rehabilitation . The

scarred palate, collapsed maxillary arch and resorbing alveolar ridges present

severe handicaps to the patient as well as a challenge to the prosthodontist.

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Retentin is probably more dependant on the skill and adaptability of the patient

than on any other factor. Application of existing knowledge and currently

available techniques of treatment can provide a more acceptable alternative.


Prosthesis in infancy period

Feeding obturator

Premaxilla positioning applilances

Nasal conformer

Palatal lift prosthesis

Speech aid or speech bulb prosthesis


Palatal obturator with solid and hollow bulbs.

Palato pharyngeal obturators with



Meatus types

Prosthesis for adults

Removable prosthesis

Complete dentures

Fixed prosthesis

Implant supported prosthesis

Feeding Obturator

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Is a prosthetic aid that is designed to obdurate the cleft and restore the

separation between oral and nasal cavities. It facilitates


Reduces nasal regurgitation

Prevents tongue from entering the defect and allows

Spontaneous growth of palatal shelves

Contribute to speech development

Reduces incidence of otitis media and other pharyngeal infections.


Preliminary impression tray is made with light polymersing acrylic resin (Triad VLC

Reline material) . Adapt in baby’s mouth and light polymerize extra orally .

Preliminary impression is made with a thick mix of tissue conditioning material

(Coc soft, GC)

While the body is held with face towards the floor.

Custom tray is fabricated. Tried intra orally determine the easiest path of


Load the tray with Viscous Vinyl polysiloxane impression material.

Impression is made as mentioned above.

Ensure proper nasal breathing and that baby is making sucking movements for border

moulding .

Pour the cast, block the undercuts and acrylic resin prosthesis is fabricated.

Review after 48 hours to detect pressure areas for ulceration .

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After 3 months a new feeding obturator can be constructed to accommodate

facial growth of the baby.

Pre-Maxilla positioning appliances

In complete bilateral cleft cases, the premaxilla for prolabium are in protruded

and rotated position.

Premaxilla positioning appliance is a non- surgical technique that retracts and rotates

the malposed segment to a more favourable position for lip repair.


A hard resin palatal plate is made from a maxillary impression.

An orthodontic button is attached to the polished surface on each side in the

area overlying gum pads.

A 1.0cm2 by 2mm thick pad of soft denture reline material is added to a

segment of an elastic orthodontic chain.

The ends of the chain is attached to the orthodontic buttons on the palate.

The tissue side of the palatal plate is lined with resilient denture reline material

for intimate contact.

The elastic chain is draped over the premaxillary segment with soft pad

contacting the prolabium .

The palatal plate provides anchorage for the elastic chain as it delivers a low

grade, steady, traction force of 5.0 grams in the premaxillary segment.

Adjustments are made periodically in the elastic chain for anterior portion of

plate to allow continous retraction.

A jack screw can be incorporated for expansion.

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Nasal conformer

Surgical repair of cleft lip can result in a flattened contour of the nasal alar


Cosmetic deformity

Nasal airway obstruction

A corrective surgical procedure needed

Gregson et al (1999) described the case of a nasal orthopedic moulding appliance to

minimize or avoid this problem.


A resin palatal plate is made for the infant at 2-3 weeks of age.

A small projection of resin extends from the plate at the plate at the cleft lip site up

toward the alar cartilage to slightly elevate it and mold it into proper contour.

This conformer is retained with denture adhesive and is work continually except for

daily cleaning until the cleft lip repair.

Patient is recalled at an interval of 1-2 weeks during use.


Velo pharyngeal in competency occurs when soft palate is of adequate length

but inadequate mobility to achieve velopharyngeal closure.

It covers the hard palate, extend posteriorly to engage the soft palate and physically

elevate and extend it into proper position to achieve closure.

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Most effective when the soft palate has little muscle tone and offers little resistance

to elevation.

Adequate retention must be achieved by clasping multiple teeth.

Treatment usually starts at the age of 4.5 (± 1 year).

It is used until the child is able to speak without any hypernasality of speech is


The speech language therapist, together with the prosthodontist evaluate any

recurring hypernasality.

Speech Aid or Speech Bulb Prosthesis

A speech aid appliances is indicated,

When speech develops for surgery cannot be performed due to systemic problems or

if surgical dehiscence has occurred.

Successful only if,

Decidous – teeth have erupted , child is co-operative with placement of orthodontic

bands and impressions.

Earliest treatment should be done at the age of 2 ½ -3 year of age.


Orthodontic bands with a single edge wire buccal tube are placed on the second

decidous molars.

Irreversible hypercolloid impressions is made

The prosthesis has 3 segments,

The palatal section with wrought wire clasps.

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The velar section

The pharyngeal or bulb section

After the palatal section is finished a wire loop is added for the velar section, to act as

a carrier for impression compound .

The level of speech bulb at the level of the palatal shelf or atlas ot at level of

passavant’s pad or ridge.

The impression for speech bulb is formed by muscle movements during deglutition.

Once acceptable closure is achieved, mouth temperature impression wax (IOWA

Wax) is added for final adaption.

This impression is then processed to fabricate the prosthesis in clear acrylic resin.

Speech bulb can also be incorporated with orthodontic appliance with Jack Screw.


An obturator can be defined as a “Prosthesis used to close a congenital or

acquired tissue opening, primarily of the hard palate and /or contiguous alveolar


Mainly 2 types:-

Palatal obturator

Palato pharyngeal obturators

Palatal obturators

Even after cleft palate surgery there may be a residual oronasal Communication in

palate, alveolar ridge or labial vestibule and cause problems of speech and feeding.It

may allow undesirable nasal air emission for compromised speech.

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A palatal obturator

Covers the opening and contribute to normal speech production.

Eliminates hypernasality for assists speech therapy.

It consists of mainly 2 portion

1. Palatal porion

2. Bulb portion

Bulb portion can be made soled or hollow

Hollow bulb has reduced weight and increased retention and assists in resonance



1. Before impression

If the opening is small, it is closed with gauze dipped in petroleum jelly

If the opening is large, the impression material is added less in the area

corresponding to the defect.

2. Preliminary impression is made using alginate if dentulous and using

compound if edentulous.

3. Custom tray is fabricated, Border molding is done. Final impression is

made with alginate or elastomeric impression material.

The scar band area must be accurately reproduced.

In dentulous, cast frame work with multiple clasping fabricated.

In edentulous, obturator is processed along with complete dentures.

Relining after necessary in edentulous cases.

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Velo pharyngeal insufficiency occur when,

The cleft palate is unrepaired or a surgically repaired soft palate is too short to make

contact with pharyngeal walls during functions causing.

Excessive nasal airflow

Inadequate oral pressure for normal speech

Nasal regurgitation during feeding

Nasal regurgitation during feeding

A palato pharyngeal obturator provides, velopharyngeal closure and contribute to

normal functions.

Mainly two parts;

Palatal portion :- Covers hard palate

velar portion - Seals the nasal

Cavity from oropharejun during function

3 General Types

1. Hinge type

2. Fixed type

3. Meatus type

Involves a mass of acrylic that is hinges to the base and supportedly move up and

down , so the cleft soft palate moves.

Not used because –

Limited motion of cleft soft palate, that a velopharyngeal seal is not possible.

Excess weight

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Fixed type(Most commonly used)- Which is directed towards passavant’s pad.

Meatus obturator :- It is directed almost 900 upward to reach the roof of


Method of fabrication of meatus obturator

Definitive maxillary prosthesis is constructed initially

A wire loop is attached to the palatal terminus of the prosthesis.

Modeling plastic is added sequentially to the wire loop to mold the obturator

As the obturator is formed, the clinician will be able to identify the indentations

formed by the inferior and middle conchae and the residual vomor.

After the obturator is formed it is reduced approximately 1mm with a scalpel for

thermoplastic wax is added.

After processing the anterior –posterior dimension of the obturator is reduced to

approximately 5 mm in thickness, to permit nasal

Breathing and to reduce weight at this juncture , the patient will exhibit hypo

nasality & nasal breathing will be difficult

Sharry suggested placing a hole approximatively 5mm in diameter through the

obturator to permit nasal breathing . Meatus obturator is indicated for patient with

extensive defects of soft plate . They are obturator of choice for edentulous

patients when retention is a problem .

Removable Prosthesis :

Removable prosthesis is preferred when there is a large anterior defect

and /or the middle third of the face is depressed

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Can be categorized into

Snap on type

Non-snap-on type

Snap- on prosthesis

In these type of prosthesis ,abutment teeth are prepared for full crowns and

Dolder or other type of bar splinting is done.

A gold framework is designed and cost to overlay the bicuspids and clasp the molars

The clip .attachment engages the anterior cross arch bar. Occlusion us restored and

middle face aesthics are achieved .A speech bulb can be incorporated in to the snap

on prosthesis .

Complete super imposed denture .

Indicated in patients with adequate veloparyngeal closure and decreased vertical

dimension of face, resulting from overclosure

Full gold crowns are placed on all maxillary teeth

Precision gold framework with claps for retention & stability for overlay denture

fabricated .

The overaly denture restores the vertical dimension of the face and gives an ideal

arch form to the maxillary arch with full compliment of teeth.

Non. Snap on prosthesis

Patient with a full compliment of teeth may need. Only a frame work clasping the

healthy abutment teeth. This framework carrier the palatal , velar and pharyngeal

portions necessary for speech improvement .

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Complete Dentures :

It is difficult to plan a complete denture for a cleft plate patient because , the

size of the maxilla will be very small. Interarch distance is usually increased and

calss III relationship is common .

Palatal vault – shallow, decreased residual ridge height , so stability is compromised

Lack of boney palate , so the support in less.

Scarring of the soft palate, so posterior palatal seal area is not recorded .

Scar tissues rebound under the pressure . Hence relief should be provided .

While impression making, small fistulous openings should be blocked out using a

gauze dipped in petroleum jelly .

Conventional border moudling is done. Impression made using light bodied rubber

base impression material

Permanent denture base fabricated.

The maxillary occlusal rim should be controlled according to the scarred lip


Lower teeth are usually set first and consecutively used as a guide to set the

maxillary anteriors .

The tooth adjacent to the labial scar usually (lateral incisor) should be set above the

occlusal plane with a slight rotation , to make the scar less conspicuous .

The labial flange of the denture should be reduced for aesthetic reason s.

An obturator bulb may be necessary to seal a posterior plate cleft. The bulbcan be

fabricated over the denture a few weeks after denture insertion .

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Fixed partial denture prosthesis

These type of repair becomes the treatment of choice when the ridge defect

is small. If bone graft was done to complete an alveolar cleft regular FPD can be

fabricated . If bone graft were not done, then FPD is done with atleast 2 abutment

on both sides of the cleft.

Stabilization of mobile premaxilla can be clone by constructing an FPD

from canine to canine.An anterior FPD & Prosthetic speech appliance framework

can be given by interlocking on the lingual aspects. When there is no tooth loss,

porcelain laminate veneers or crowns may be placed on an abnormally shaped

lateral incisors .

Implants :

1. Implants can be placed to replace single missing tooth

eg: lateral incisor .

2. Support an FPD implant can act as an abutment .

3. In edentulous case, over denture can be made over the implants ie implants

supported over dentures .


Prosthodontic treatment has a long and rich history in the care of patients

with cleft lip& palate . Because of increased knowledge of craniofacial

growth and development and improved surgical and orthodontic treatment ,

today’s cleft palate patients receive better care and in len time. This requires

less prosthetic intervention . still prosthetics retains an important place in

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cleft care and prosthodontist remains an integral member of cleft –

craniofacial rehabilitation team .

References :

1. Maxillofacial rehabilitation - prosthodontic & surgical considerations –

john Beumer , Thomas . A curtis & David.N.firtell

2. Maxillofacial prosthetics – multi disciplinary practice – Varoujan A chalian,

Joe.B. Draine, S.Miles. Stantish

3. Complete denture prosthodontics - John J.Sharry

4. Dental & prosthodontic care for patients with cleft or craniofacial

conditions - David . J.Reisberg

5. The cleft plate – Vol.37 , No.6,P.534-537 . Facial clefts & cranio synostosis –

principles & management . Thimothy

A.Tinvey .

6. Treatment of facial cleft deformities – An illustrated guide –kurt.W.Butou.

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