Presentation Cleft Palate

By: Dr Bushra Jabeen

Cleft palate from the prosthetic aspectA cleft palate may be defined as a lack

continuity of the palate. It may be congenital or acquired as a Result of injury or disease.

Cleft lip and cleft palate are birth abnormalities of the mouth and lip.Cleft palate occurs when the roof of the mouth does not completely close, leaving an opening that can extend into the nasal cavity. The cleft may involve either side of the palate. It can extend from the front of the mouth (hard palate) to the throat (soft palate). Often the cleft will also include the lip.

Cleft palate from the prosthetic aspectCleft lip is an abnormality in which the lip

does not completely form during fetal development. The degree of the cleft lip can vary greatly, from mild (notching of the lip) to severe (large opening from the lip up through the nose).

Cleft palate from the prosthetic aspectThere are different names given to the cleft

lip according to its location and how much of the lip is involved. A cleft on one side of the lip that does not extend into the nose is called unilateral incomplete. A cleft on one side of the lip that extends into the nose is called unilateral complete. A cleft that involves both sides of the lip and extends into and involves the nose is called bilateral complete.

Cleft palate from the prosthetic aspectThe exact cause of cleft lip and cleft palate is

not completely understood. Cleft lip and/or cleft palate are caused by multiple genes inherited from both parents, as well as environmental factors that scientists do not yet fully understand.

CLASSIFICATION

Failure of union at any stage will result in a congenital cleft palate which may be classified, as

Class 1 clefts involving soft palate only.Class 2 clefts involving soft and hard palates

up to incisive foramen.Class 3 clefts of soft and hard palats, forwards

through alveolar ridge and continued in to lip on onside.

Class 4 same as class 3 but associated with bilateral cleft – lip.

CLASSIFICATION Another classification has relevance to the

surgically repaired congenital cleft lip and palate and acquired clefts from injury or elective surgery is as follow:

Enclosed defects Soft palate.Hard palate.Hard and soft palate.Open- end defectsAnterior unilateral (or, very rarely, bilateral ).Posterior.Anteroposterior.

PROBLEMS OF CONGENITAL CLEFT PALATE

feeding difficultiesFeeding difficulties occur more with cleft palate abnormalities. The infant may be unable to suck properly because the roof of the mouth is not formed completely.

ear infections and hearing lossEar infections are often due to a dysfunction of the tube that connects the middle ear and the throat. Recurrent infections can then lead to hearing loss.

PROBLEMS OF CONGENITAL CLEFT PALATEspeech and language delay

Due to the opening of the roof of the mouth and the lip, muscle function may be decreased, which can lead to a delay in speech or abnormal speech. Referral to a speech therapist should be discussed with your child's physician.

dental problemsAs a result of the abnormalities, teeth may not erupt normally and orthodontic treatment is usually required.

CLEFT HARD PALATE

Repaired surgically .Orthodontic treatment .A denture may be necessary to maintain the

expansion and obdurate the open cleft

PROSTHETIC TREATMENT OF SOFT PALATE CLEFTS

The treatment of clefts in the soft palate is by means of and obturator , some times called a speech bulb.

TYPES OF OBTURATOR

Obturators are of three types Fixe pharyngeal.Hinged pharyngeal.Meatal.

TYPES OF OBTURATOR

The fixed is an extension of a denture projecting in to the pharynx at about the level of the anterior arch of the atlas and shaped so that it can be griped by the pharyngeal walls.

The hinged is attached to the posterior border of a denture by a hinge and its lateral borders are shaped so that they may be griped by the remnants of the soft palate and be raised and lowered with them .

TYPES OF OBTURATOR

The meatal obturator is an extension of the back of the denture, upwards at right angles to It, so that it occludes the opening of the posterior nares.

The meatal obturator is only used in cases presenting a very large cleft and is difficult to adjust so that it prevents the nasal escape of air when speaking the oral consonants and does not help the patient when swallowing.

Treatment options

In cleft palate pharyngeal extension on the speech obturator can be used.

In this case report complete denture with hollow pharyngeal bulb prosthesis has been used for rehabilitation of an edentulous patient having cleft of soft palate.

Case report

A 58-year-old female patient came to the department of prosthodontics and maxillofacial prosthetics, with complaint of missing teeth. Teeth were lost 28 years back due to periodontitis. No significant past medical history recorded and history of previous denture wears. Intra-oral examination revealed completely edentulous upper and lower arches, cleft of soft palate (Veau's classification[5] - group I) with velopharyngeal incompetence, nasal regurgitation.

Treatment planning

Surgical treatment option was eliminated considering age, systemic health and economic status of the patient. Prosthodontic treatment was decided with complete denture with hollow pharyngeal bulb prosthesis.

Procedure

Upper and lower perforated stock trays were selected. Upper tray was modified with wax extension into the defect to record the defect. Then upper and lower preliminary impressions were made with irreversible hydrocolloid. The upper impression also records the defect. Impressions were poured with dental stone to make diagnostic casts. Next step is the fabrication of special tray for border molding. Lower special tray is fabricated in conventional manner using autopolymerising acrylic resin. But during the fabrication of upper tray following factors were kept in mind.

Procedure

There should be a 5 mm gap between the bulb and posterior pharyngeal wall.

Angle of the bulb should be approximately 20° relative to the palatal plane.

Keeping in mind all these criteria upper special tray was fabricated with autopolymerising acrylic resin having pharyngeal extension.

Border molding was accomplished by recording all the functional movements of the soft palate, i.e., by asking the patient to tilt her head side-to-side and front-back when sitting upright. Impression of the defect area was made with impression compound. Lower Border molding was done in conventional manner. Upper final impression was made with medium body polyvinyl siloxane and lower with ZnOE. Boxing was done and impressions were poured with die stone to fabricate master casts.

Procedure

Autopolymerising acrylic resin record bases were made. In case of upper record base did not include the pharyngeal extension. Occlusal rims were made. Jaw relations and try in was done in accordance with conventional complete denture fabrication procedures.

After try in was over, all the undercuts of the defect area were blocked with wax. Flasking and dewaxing was done. Then dentures were processed with heat cure acrylic resin. Lid for the bulb was processed separately with heat curing acrylic resin and was attached to the completed denture with autopolymerising acrylic resin.

Procedure

Upper and lower dentures were finished and polished. Patient was instructed in the use of the denture.

Patient found drastic improvement in speech and nasal regurgitation was reduced. Patient was advised to continue her referral to speech therapist.

. Once surgical care and speech therapy have been completed, the need for follow-up care is needed unless specific problems manifest. Preventive care is imperative if long-term preservation of the supporting structures is desired.

SILICONE RETENTIVE OBTURATOR

In congenital clefts of the hard palate , enclosed or open- ended, and acquired clefts , a use ful form of obturator is made of silicone ( or latex rubber ) which is attached to the denture by studs .

The obturator is remov able and adjustments can be made . the design is useful in the edentulous cleft patient and in large acquired defects of the palate where retention is a major problem.

STAGES

Cut a postdam 5mm from the edge of the cleft on the master cast .

Fill the cleft with wax and carve to the contour of a normal palate .

Add a sheet of wax .Embed two studs.Take an impression of the cast in elastomer .Add to studs to the impression and pour it to

produce a working cast.

STAGES Use working cast to make a complete denture. Pour a plaster register to the master cast to hold

the studs in relation to the cleft.Fill the cleft with silicone rubber in produce the

obturator which is retained on the studs on the denture.

The master cast serves as a permanent mould for replacement obturators .

If soft palate obturation is required then gutta-percha can be added to the silicone obturator and, after moulding in the mouth , returned to the master mould and studs prior to making a new , accurate mould.

ACQUIRED CLEFTS

Enclosed defectsOpen –end defects