The Cleft Palate Patient

8/13/2019 The Cleft Palate Patient

http://slidepdf.com/reader/full/the-cleft-palate-patient 1/4

Prosthodontics

rehabil i tation—Clinical report

Denis Vojvodic, DDS, MDS, PhDWjekoslav Jerolimov, DDS, MDS, PhD^

Although cleft palate pati9nts are nol regularly seen m general denial practice, their number is not

negligible. P rest h odontic treatrriGnl of su ch pa lienls requires go od planning that takes into account ail

remaining teeth and roots, deformation ot maxillary segments, residuai palatal defects, and the

dispro portio n betw een the m axiilary and m andibular alveolar ridge. With the aim to provide satisfactory

function and esthetics and alleviation of the deformities, fhe authors describe prosfhefic therapy of a cleft

paiate patient using roof copings, atfachmenfs, telescope and cone crowns, and a metal-base partial

prosthesis. The pafient's masficafion, phona tion, and esfhefics were improved. Successful resuits can be

besf achieved through fhe judicious use of appropriate treatment modalities lempered by clinical

experience and creativity. Quintesser)ce Int 2001:32:521-524)

Key w or ds : cleft palate, prosthodontic reh ^i l i fa tio n, roof coping, telescope crown

A lthough cleft palate patients aie not regularly seenin general dental practice, their number is not

negligible. This congenital anomaly is one of the most

freqtient ones; one in every 800 hirths results in a cleftlip and/or palate.' Cleft palate/lip etiology is stiJl notclarified, but possible causes are malnutrition and iira-diatioii during pregnancy, psychic stress, teratogenicagents, infectious agents (vinises), and heritage (onethird to one half of cleft palate/lip patients have previ-ous appearances of this anomaly in their family).

Between the 21sî and 31st days of intratiterine ufe,five mesenchyme processes covered with ectoderm are

oral cavity. The processes grow with the swelling of

tistry, University of Zagreb, Croatia,

Prostho dontics. University o l Zag re 0, Croatia.

Dr Denis Vo|vodic. Clinical Hosprtal Dubrava. Clinical

Maxillary processes first merge with the lateralnasal swelling (the naso-optical furrow that developsin the nasolacrimal ductus) and then with the medial

nasal swelling,'-^ Together, they create the primarypalate at 6 weeks, which starts to separate the oralcavity from the nasal cavity.' Joining of the palatalshelves begins at 10 weeks, after the soft tissue hasfused, and lasts until 14 weeks, when bone support isestablished, thus completing the separation of the oralcavity from the nasal cavity.'-^ Morphologic variationsof the clefts are so large that it can be said that everycleft is a unique one.

For the rehabilitation of such a complex problem, itIs obvious that a team of different medical and dental

specialists is needed. The required specialists fromdentai fields are orthodontist , pedodontist , andprosthodontist.

Orthodontic therapy takes place before (he surgicaltreatment to assist the surgeons'; the orthodontist'stask is to reduce the gap between the segments, tostimulate the palatal bone growth,^'-^ to correct themalformations of the alveolar ridge ^ as well as to easeand improve the feeding of the child with the cleft.'-^

A pedodontist treats the remaining teeth {frequenthyp odo ntia),' especially those with enamel hjipopla-sia as a consequence of surgical trauma. Surgical treat-

ment takes place at the age of 6 months to 2 years,and is usually performed at about 18 months of age,^when ailiculated speech begins.

f esse nee Internalional 521



• Vojvodic/Jerol imov

Surgical treatment bas a negative effect on maxil-lary growtb because of scar tisstte developtnent. Asmore scar tissue develops, tbe consequences becomegreater- Matiy autbors attest to severe maxillary defi-ciency in all dim ens ions , dram atic effects on maxil-lary growth (in cases in which the bone grafting to tbe

cleft area is done early),'- an often concave facialskeleton profile in ad ttlth oo d, and severe effects onthe dental arches (contraction in the sagittal andtransverse planes) if the scars run close to the teeth *;Ross'^ described tbe scar tissue effect as maxillaryankylosis-

Because of tbe aforementioned reasons, repeatedoperafions more often increase tbe deformations (newscar tissue) rather than further the correction of thecondition after the first treatment; a reducfion in thenumber of operations is recommended. General clini-

cal experience reveals tbat the sooner tbe surgicaltreatment is performed, the more drastic the scar tis-sue effect becomes. Tberefore, some tberapists suggestdelay of tbe bard palate surgery (excluding early bonegrafting) unfil the child is 8 to 10 years old to providesufficient time for tbe growtb and development of tbemaxilla.'*'

In adulthood, the task of the prosthodontist is torestore the lost teeth and parts of the alveolar ridge toobtain function, esthetics, and alleviate the deformifiesas much as possible.

CLINICAL REPORT

A 23-year-old female patient with a surgically treatedbilateral cleft lip and palate was examined in theClinical Department tor Prosthodontics at the Schoolof Dentistry, Universi ty of Zagreb, Croatia.Examination revealed persistent communication withthe nasal cavity at the hard palate, a so-called residualpalatal defect with d imen sions of 2 mm X 3 mm,through which liquids periodically entered the nasal

cavity while drinking- Chewing abilities and estheticswere very poor because of the lost teeth and maxillarydeficiency. The whole premaxilla was practically miss-ing, including all maxillary incisors and the rightcanine- The maxillary left canine, second premolar, andfirst molar had heen endodontically treated but hadsevere crown destruction. Other remaining teeth hadamalgam fillings without secondary decay (Fig 1). Thevertical dimension of occlusion remained constant andnormal, and it was 3 mm above rest posifion,'* but witba cross bite hecause of the maxillary deficiency (Fig 2).

The roots of tbe nonvital teetb were prepared, andindividual cast-metal posts and cores were made fortbe maxillary second premolar and the first molar- Aheavy-body silicone impression witb Degufiex impres-

sion material (Degussa) was made. Retraction cordswere placed in tbe gingival sulci of tbe prepared teethand removed after 4 minutes. A small piece of gauzecoated witb petroleum jelly was placed over the resid-ual palatal defect, and a light-body impression mater-ial (Xantopren L, Heraeus Kulzer) was put over the

prepared teeth with a syringe (Fig 3). Tbe beavy-bodyimpression was covered witb a ligbt-body material,and the tray was piaced in tbe m outb.

Tbe gauze coated witb petroleum jelly was put overtbe residual palatal defect so that the light-body sili-cone impression material could not enter tbe nasal cav-ity (Fig 4). If some of the light-body silicone materialentered tbe residual palatal defect, its pedicle couldbreaii during tbe removal of the impression from themouth, causing probierns in removing tbe retained part.

For tbe root of tbe maxillary left canine, a coping

with intraradicular retention was made with a DallaBona stud attachment (Servo Dental). On all maxil-lary premolars, telescope crowns were placed, and acone crown was designed for the maxillary right firstmolar (Fig 5). This solution was chosen to providegood retention and to ensure that the patient wouldenjoy a better feeling of security,'' esthetics withgreater freedom for correct tooth positioning, andmore favorable loading conditions for tbe abuttnentroots^ '^' with regard to the disproportion hetween tbetwo alveolar ridges.

All metal parts were cast from a gold-platinum alloy18-1-8 (Precious Metals Refinery) to provide durabilityof the construction parts that would be submitted tofriction. The metal basis of the denture was made fromCo-Cr alloy (Remanium GM 380, Dentaurum). Thepalatal part of the prosthesis was used as an obturatorto facilitate drinking, disabling the entrance of liquidinto the nasal ca vi ty . Despite the deformities, tbefinal recons tructive denture bad safisfactory occlusionand articulation with the natural mandibular teeth ig 6 ),

CONCLUSION

Clefi palate patients with maxillary bone and tootbloss present a significant challenge for prostbefic reha-bilitation. In this case, as in any case, the patientdesired to improve her mastication, phonation, andesthetics. These results can be best achieved throughthe judicious use of appropriate treatment modalifiestempered by ciinical experience.

For a successful rehabilitation of cleft palate

patients, it is indispensable to take care of all teethand roots (even tbose tbat look unsuitable), becausesignificant hone loss can interfere with or prevent theselection of acceptable implant sites. Consequently,

52 2 Voiume 32 Number 7 2001



Vojvodic/Jerolimov •

Rg 1 Siiijaiion in iti maxiila D eioie prosmeuc ¡¡eauTieni. i 2 Patents maximum intercuspation.

i 3 Placement ot a l ight-body impression material: gauze Fig 4coated witti patraleum jelly is piaced over ttie residual paiataidetecL

Rg 5 Rxed prosthetic appliances set in plaoe root coping withDalla Bona atiacnmeni and inner telescopes).

i 6 Reconstructive prostnesis in occlusion wah natural mandi-

buiar teeth.

Quintessence intemalional523



• Vojvodic/Jeroiimov

inadequate retention of a reconstructive prosthesis cancause difficulties in mastication and communicationand can affect esthetics. During prosthetic therapyplanning, one should take into consideration theremaining roots and teeth, deformation of maxillarysegments, residual palatal defects, as well as the dis-

proportion hetween the maxillary and mandihularalveolar ridges. Experience and creativity are neededto achieve the desired prosthetic réhabilitation. Well-planned prosthetic therapy wiil result in satisfactoryfunction and esthetics, providing alleviation of thedeformities.

REFERENCES

1. Moyers RE. Hand book of Orthodontics, cd 4. Chicago. YearBook Medical, 1988:19-27.

2. Epker BN, Fish LC. Dentofacial Deformities. IntegratedOrthodontics and Surgical Correction. St Louis: Mosby,1986:640-709.

3. Kjaer I. Human prenatal craniofacial development relatedto brain development under normal and pathologic condi-tions. Acta Odontol Scand 1995;53;135-143.

4. Shapiro M. The Scientific Bases of Dentistry. Philadelphia:WB Saunders, 1966:75-79.

5. Lubif EC. Cleft palate orth opedics. Why, when, how. Am JOrthod 1976:69:562-571.

6. Brogan WF, McComb H. The early management of cleft lipand palate deformities. Aust Dent J1973; 18:212-217.

7 Graf-Pinthus B, Bettex M. Long term observation followingpresurgical orthopedic treatment in complete clefts of thelip and palate. Cleft Palate | 197 4;ll:25 5-26 0.

8. Holz M . Aims and po ssibilities of pre and po st surgicalorthopedic treatment in unilateral and bilateral clefts. TransEur Orthod Soc 1973;553-558.

9. Mcliinstry RE, Browning S. Microwave processing of cleftpalate orthopedic expansion devices. | Prosfhet Dent 1992;67:882-886.

10. Hobkirk [A, Brook AH. The management of patients withsevere hypodontia. Oral Rehabil 1980;7:289-298.

11. Graber TM. Craniofacial morphology in clelt palate andcleft lip deformities. Surg Gynecol Obstef 1949;88:359-369.

12. Friede H, Johansonn B. Adolescent facial morphology ofbone-grafted cleft lip and palate patients. Scand ] PlastReconstrSurg 1982; 16:41-53.

13. Friede H, Pruzanslty S. Long-term effects of premaxillarysetback on facial skeletal profile in complete bilateral cleftlip and palate. Cleft Palate ] 1985;22:97-105.

14. Friede H, Persson E-C, Lilja J, Blander A, Lohmander-Agerskov A, Soederpalm E. Maxillary dental arch andocclusion in patients with repaired clefts of fhe secondarypalate. Scand Plast Reconstr Surg 1993 ;27:297-305.

15. Ross RB. The c linical im plications of facial grow th in cleftlip and palate. Cleft Palate 1970;7:37-47.

16. lohanson B, Lilja J, Friede H , Moeller M, Lauritzen C. Theevolution of the therapeutic approach to eleft lip and palatein Gothenburg. In: Hotz M, ef al eds]. Early Treatment ofCleft Lip and Palate: Proceedings of the Third internationalSymposium, Univ of Zurich. 27-29 Sept 1984. Toronto: HHuber, 1986:85-89.

17 Friede H. Abnorm al facial gro wth. Acfa Od onto l Scand1995;53:203-209.

18. Posselt U. Intermaxillary relations. In: Sharry JJ ed). Com-plete Denture Prosfhodontics. New York: McGraw-Hill,1962:187-217.

19. Preiskel HW. Precision Attachm ents in Dentistry, ed 2. StLouis: Mosby, 1973:112-140.

20. Basker RM, Harrison A, Ralph JP, Watson C]. O verdenturesin General Denfal Practice, ed 3. London: British DentalAssociation, 1993:49-65.

21 . Siddiqui AA, Toljanic JA. Adap tation to removable prosthe-sis. I Prosthet Dent 1993;70:283-284.

22. Desiardins RP. Obturator prosthesis design for acquiredmaxillary defects. J Prosthet Dent 1978;39:424-435.

23 . Shimodaira K, Yoshida H, Mizukami M, Funaliobo TObturator prosthesis conforming to movement of the softpalate. ] Prosthet Dent 1994;71:547-55L

Erratum

In Table 2 of the article Effect of calcium removal ondentin bond strengths by Perdigäo et al (QuintessenceInt 2001;32:142-146), the mean bond strength of

Prime&Bond NT applied to an undecalcified dentinal sur-face (control) should be 23.0 MPa, not 2.3 MPa as pub-lished. The author and publisher regret this error.

524 Volume 32, Num ber 7, 2001

The Cleft Palate Patient

Documents