Prosthetic management of cleft lip and palate patient

Prosthetic management of cleft lip and palate

Presented by Sanjiv Bairwa

PG 1st yr Prosthodontics Dept.Jaipur dental college

Introduction Classification Impression material Impression position Impression trays Feeding plate Tooth replacement Conclusion References

Contents

The oral rehabilitation of individuals with cleft lip and palate is directly related to severity of anatomical and functional alterations determined by malformation and the age at treatment.

The ideal treatment of cleft area is closure by bone graft and orthodontics, when this not feasible, many cases are solved with prosthetic rehabilitations.

Introduction

According to mazaheri, 60% of individuals with clefts will require some type of denture, and this percentage tends to increase if cleft affects the alveolar ridge.

The prosthetic rehabilitation contributes directly and positively to the psychological aspects of individual.

The main prosthetic treatment involved in oral rehabilitation of the individuals with cleft lip and palate are --

Fixed partial denture Removable partial denture Complete denture Implant-supported denture.

Anatomy

Orbicularis oris

Cupids Bow Philtral column Dimple

Vermilion border

Tubercle

Any opening or division inSome part of anatomy thatIs not normally open or Divided.

What is cleft ?

What is Cleft lip or Palate

Cleft lip

Class 1: incomplete cleft involving only the soft palate

Class 2 :cleft involving the hard and soft palate

Class 3 :complete unilateral cleft involving the lip and palate

Class 4 :complete bilateral cleft

Veaus classification

Teamwork

Surgery

Dentistry - Pedodontist Orthodontist Prosthodontist Maxillofacial surgery

Speech therapist

Audiology

ENT

Pediatrics

Psychology

• Elastomeric impression material.

Polyvinyal siloxane

• Irreversible hydrocolloids

Alginate • Low fusing and

medium fusing impression compounds.

Green stick

Impression materials

Impression compound

It is a thermoplastic impression material and used for impressions of infant with oral clefts.

Impression compound

•Easy removal

•Better resistance

Advantages

• Scalding or burnDisadvantages

Green stick compound is a low fusing impression compound.

Advantage Softened easily and quite Hard on setting

Disadvantage Can cause burn

Low fusing impression compound

AlginateAdavnatge Ease of mixing and manipulation Economical Pleasant color and taste

Disadvantage Poor tear strength

Irreversible hydroclloids

Use of Fast setting color timed alginate has been suggested in cleft infants , which has advantages to record the details even in presence of saliva.

Advantage Comfortable to patient Easy to manipulate Relatively inexpensive Prevents respiratory arrest

Elastomeric impression materialElastomeric impression materialsare better suited in making of cleftimpression and they don’t lead toany complications.

Advantage good elastic behaviour high tear strength accurate reproduction of surface detail long term dimensional stability

In Infants The most important part of the oral rehabilitation of

a patient with cleft lip and cleft palate is the impression making procedure.

The making of the impression in an infant with a cleft palate is a critical procedure.

For an accurate and safe impression procedure, a proper patient and dentist position are vital.

Impression position

A no. of impression positions have been adopted for cleft palate in infants are --

Positions

Facedown

Upright

Prone

Upside down

Facedown position

Upright position

Selection of Impression trays

• Use of wax• Icecream stick

• Hand adaptation

• Reverse side of spoon

Use of wax

Prefabricated trays that are commercially available(coe laboratory, chicago)for cleft palate impressions in infants.

Shatkin and stark described the use of a wax as impression trays in cleft lip and palate patients.

Icecream sticks can also be used to carry materials for infant impressions.

The prosthetic treatment in infants includes--

Improve feeding Tongue function Speech development

It reduces the risk of aspiration the as oro-nasal communication is eliminated and it is an easier procedure with good aesthetic results.

Prosthetic care for infants

Feeding obturator

Feeding plate obturates cleft and restores the separation between oral and nasal cavities.

It aid in creating sufficient negative pressure which allows adequate sucking of milk and creates a rigid platform towards which baby can press nipple and extract milk.

Feeding appliances

It facilitates feeding by –

• Reduces the nasal regurgitation .

• Reduces the incidence of choking and shortens the length of time required for feeding.

• It restore the basic function of mastication , Deglutition , speech production until cleft lip or palate can be surgically corrected.

Primary impression was made with molding with low fusion impression compound with hand adaptation to the palate of the patient.

The infant was held upright by mother to prevent aspiration of any extra material.

Primary cast was fabricated by dental stone( type 3 gypsum product )

Fabrication of feeding plate

Showing the primary impression

A customized special tray fabricated by auto polymerizing acrylic resin.

The final impression made by rubber base impression material to record the precise detail of supporting structure and defect.

Customized special tray

Final impression

Master cast fabricated and excessive undercuts blocked out with modeling wax.

Wax pattern of the feeding plate adapted on master cast. Flasking , de-waxing done and feeding plate fabricated with heat activated clear acrylic for obturating the defect in the soft palate involving uvula.

Master cast with block out

Palatal plate on master cast

Palatal plate with thread

Feeding plate

Extra oral view

Intraoral view

Tooth replacement

Options for tooth replacement includes--

Fixed or removable partial

dentureComplete denture Dental implants

Impression materials used for young patient

Elastomeric impression

material

Irreversible hydrocolloids

Due to alteration of alveolar ridge of individuals with cleft lip and palate patient, the rehabilitation with complete denture is challenging to dentist.

Complete denture

Denture stability

Physical factors

Retention

Difficulties are --

Unrepaired clefts

Presence of fistula

Alveolar ridge anato

my

Open ridges with wide cleft

Impression

Anatomical

Functional Stock tray

Addition

Condensation silicon

In case fistula

present or not

Impression

Anatomical Functional

Stock tray Fistula absent

Fistula present

High fusing impression compound

High fusing impression compound

A removal partial denture is most often used but it is a temporary form of tooth replacement.

R.P.D are especially indicated in patients with tissue deficiency several fistulas, soft palate dysfunction or uncoordinated nasopharyngeal sphinctor action.

Removable partial dentures

Although it provide good esthetics , it rests on soft tissue of the palate and causes irritation.

Planning of R.P.D should be combined to clinical & radiographic examination & dental cast analysis and occlusal analysis and determination of site of retainer , connector and dental bar.

There may be movement of the prosthesis during function. Hence it is used only as a definitive means of tooth replacement in which multiple teeth are missing and the edentulous space is too long to be spanned by a fixed restoration and when patient cannot afford implants.

A fixed partial denture attaches to teeth on each side of edentulous space to provide a more natural tooth replacement

If the abutment teeth need no other restoration then a resin bonded fixed

Fixed partial denture

It provides a more natural tooth replacement. Whenever , possible conservative , i.e. resin

bonded fixed partial denture should be provided for anterior replacement only.

This conservative restoration requires very little tooth preparation, and provides excellent appearance and function.

Alternatively , a conventional fixed partial denture can be used. This provides long – term success.

Conclusion Prosthodontist are one of member of multi

disciplinary cleft team. In the care of patient with cleft lip and palate

prosthetic treatment retains an important place.

Prosthodontist must be able to diagnosis the defect and provide a preventive, interventional and rehabilitative treatment to reduce the impact of the defect in patient quality of life.

Maxillofacial rehabilitation : Prosthodontic and surgical considerations by Beumer.

Clinical maxillofacial prosthetics by Taylor.

Dentistry for the child and adolescent by Mc’donald and Averys 9th edition.

Textbook of Pediatric dentistry :by Damle. 2nd edition.

Textbook of Pediatric dentistry by Nikhil Marwah 2nd edition.

Internet.

References

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