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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 35-40

Esthetic and Functional Rehabilitation of an Adult Cleft Lip and Palate Patient Using Combined Fixed and Removable Prosthesis


1 Department of Prosthodontics, Government Dental College, Alappuzha, India
2 Department of Prosthodontics, Government Dental College, Kottayam, Kerala, India

Date of Web Publication5-Mar-2018

Correspondence Address:
R M Geethu
‘Mercy’, TC 16/1341 (1), Kannettumukku, Thycaud P. O., Trivandrum - 695 014, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_26_17

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   Abstract 


Successful oral rehabilitation of adult patients with cleft lip and palate requires definitive fixed or removable prosthesis to assist orthodontic and orthognathic treatments. Prosthetic rehabilitation aims to improve the functional and esthetic demands and provides better oral health. The aim of this case report is to introduce a prosthetic approach for functional and esthetic rehabilitation of an adult male patient with surgically repaired cleft lip and unrepaired palate, by a combination of fixed dental prosthesis with an extracoronal attachment retained gingival veneer and a cast partial hollow-bulb obturator.

Keywords: Cast partial hollow-bulb obturator, cleft lip and palate, extracoronal attachment retained gingival veneer, fixed dental prosthesis


How to cite this article:
Geethu R M, Anilkumar S. Esthetic and Functional Rehabilitation of an Adult Cleft Lip and Palate Patient Using Combined Fixed and Removable Prosthesis. J Interdiscip Dentistry 2018;8:35-40

How to cite this URL:
Geethu R M, Anilkumar S. Esthetic and Functional Rehabilitation of an Adult Cleft Lip and Palate Patient Using Combined Fixed and Removable Prosthesis. J Interdiscip Dentistry [serial online] 2018 [cited 2020 Oct 25];8:35-40. Available from: https://www.jidonline.com/text.asp?2018/8/1/35/226637




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Surgical Corrections alone, of Cleft Lip and palate often do not provide complete esthetic and functional rehabilitation of the patient.
  • Multidisciplinary approach involving oral and maxillofacial surgery, Periodontics, Endodontics and Prosthodontics is used for satisfactory rehabilitation.
  • Extraction of Grossly decayed teeth, Root canal treatment of abutment teeth and oral prophylaxis is done as mouth preparations to receive the final Prosthetic rehabilitation.
  • The Prosthetic rehabilitation is done using a combined fixed and removable three piece prosthesis.



   Introduction Top


Restoration of patients with unilateral or bilateral cleft lip and palate with missing anterior teeth and deficient alveolar ridge presents a challenging task for the dentist. Even though patients with cleft lip and palate are rare presentations in general dental practice, it is considered to be one of the most common congenital deformities of the orofacial complex with a prevalence rate of one in 600–1000 live births.[1]

Morphologically, they are classified into four major types: cleft lip, cleft palate, unilateral cleft lip and palate, and bilateral cleft lip and palate. Cleft lip and palate has a multifactorial etiology,[2] and results from the failure of fusion of median and lateral nasal processes and palatal shelves. Besides affecting esthetics cleft lip and palate also result in a severe functional deficiency of mastication, swallowing, and speech. These defects usually present with anomalies such as variations in tooth number, tooth shapes, and their positions. The tooth most frequently affected is permanent lateral incisor.[3]

Oral rehabilitation of individuals with cleft lip and palate is directly related to the severity of anatomical and functional malformations and the age at treatment onset.[4] Each case should be considered with a specific rehabilitation strategy which includes multidisciplinary treatment planning by surgeons, orthodontists, and restorative dentists.[5] Even though, the ideal treatment of the cleft area is closure by bone graft and orthodontics;[6] many cases are rehabilitated with a variety of prosthetic appliances, including conventional or implant-assisted removable dentures, fixed dental prosthesis (FDP), resin composite veneered multi-unit FDP, fiber-reinforced composite resin bonded FDP, removable partial denture with extracoronal attachment, and combination of fixed and removable dental prosthesis.[7] Maxillofacial prosthetic treatment aims to reestablish the esthetic and functional health of patients with craniofacial defects. According to Mazaheri, 60% of individuals with clefts will require some types of the denture, and this percentage tends to increase if the cleft affects the alveolar ridge.[8]

This article presents a case report of an adult male patient with surgically repaired cleft lip and unrepaired palate, rehabilitated by a combination of FDP with an extracoronal attachment retained gingival veneer and a cast partial hollow-bulb obturator.


   Case Report Top


A 25-year-old male patient with a surgically treated unilateral cleft lip and unrepaired unilateral complete cleft of the primary and secondary palate on the left side was referred to the Department of Prosthodontics, Government Dental College, Kottayam for prosthetic rehabilitation.

A preoperative extraoral examination [Figure 1] revealed facial asymmetry, repaired unilateral cleft lip on the left side with distinct atrophic scar contracting the upper lip, concave profile, retruded upper lip, the reduced thickness of the vermillion part of the upper lip, prominent lower lip, and positive lip step.
Figure 1: Preoperative extraoral view

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Intraoral examination revealed [Figure 2]a and [Figure 2]b a 4 cm × 4 cm residual palatal defect extending rightward to the alveolar ridge and hyperplastic soft tissue surrounding the hard palate defect. The defect caused a space between upper right lateral incisor and central incisor with a large oronasal communication, leading to nasal reflux of food and water and distorted articulation.
Figure 2: (a and b) Preoperative intraoral view

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The upper left lateral incisor was lost due to caries. The gingival margins of the right lateral incisor were at a higher level than the central incisors due to the bone and soft tissue loss caused by the tissue defect. The upper right central incisor was rotated mesially. Oral hygiene status showed generalized moderate-to-severe plaque and calculus due to irregularly positioned and displaced teeth. 16 and 26 were found to be grossly decayed. The mandibular arch was found to be intact and stable.

Following comprehensive diagnosis and treatment, it was decided to rehabilitate the maxillary anterior segment with an FDP and an extracoronal attachment retained gingival veneer. The residual palatal defect was to be restored with cast partial hollow-bulb obturator prosthesis.

Treatment was planned in the following steps:

  1. Extraction of grossly decayed 16 and 26
  2. Oral prophylaxis
  3. Fabrication of FDP with an extracoronal attachment retained gingival veneer
  4. Fabrication of Cast partial hollow-bulb obturator prosthesis.


Following extraction of 16 and 26 and full mouth oral prophylaxis, diagnostic impressions were made, and working casts were poured in Type II dental stone. A diagnostic wax-up was made to know the ideal teeth alignment and the tooth reduction needed for abutments. It was decided to use one more pontic (except the left incisor pontic) to restore the defect area between upper right lateral and central incisor. For best esthetic results the additional pontic was restored as a lateral incisor. The missing hard tissue and soft tissue on the labial side was complemented with an attachment retained acrylic gingival veneer.

After thorough clinical and radiographic analysis, it was decided to choose both central incisors, both canines and right lateral incisor as abutments. Intentional endodontic treatment was done for all the abutment teeth as they were rotated and for the long-term prognosis of the prosthesis. The abutment teeth were prepared to receive a metal-ceramic FDP [Figure 3]. The impression of the prepared teeth was made using one-stage putty-wash technique. After routine laboratory procedures, the accuracy of fit of the metal framework with extracoronal attachment was checked intraorally. Following addition of veneering ceramic, pink porcelain was added at the gingival margins of right lateral incisor abutment and pontic as the margins were not at the same level of the other abutment teeth. A bisque try-in was performed before the final prosthesis was cemented. The final prosthesis with extracoronal attachment on the labial side was luted with glass ionomer cement [Figure 4]. The patient was recalled after 1 day for impression making of the attachment retained gingival veneer. A custom tray was fabricated, and impression of the missing hard and soft tissue on the labial side was made using light body and casts were poured in Type II dental stone. Wax try-in of the gingival veneer was done intraorally. Following routine flasking and deflasking procedures, the finished acrylic prosthesis was tried and inserted [Figure 5].
Figure 3: Teeth preparation

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Figure 4: Fixed dental prosthesis with ball attachment

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Figure 5: Fixed dental prosthesis with attachment retained gingival veneer

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The patient was recalled after 1 week for rehabilitation of the residual palatal defect. Using a perforated stock tray, preliminary impression of the maxillary and mandibular arches was made and casts poured. The obturator framework was designed according to the Kennedy Class III RPD design. Cast circumferential clasps were planned on abutment teeth adjacent to the edentulous space for direct retention, and remaining seats were given on the right and left canines for indirect retention. The primary casts were surveyed, and necessary mouth preparations were done intraorally. The definitive impression of the maxillary arch was made using putty-wash technique and casts were poured in Type III dental stone. RPD framework was waxed on the refractory cast and casted in the base metal alloy. The metal framework was finished, polished, and tried intraorally [Figure 6].
Figure 6: Cast partial metal framework try-in

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Using the metal framework as tray the defect area was recorded using modified impression compound and was relined using the light body. Following which a pickup impression of the remaining natural teeth was made using putty material [Figure 7] and master casts were obtained in Type III dental stone. The metal framework was then separated from the master cast, jaw relations were recorded and wax try-in was performed. A closed, hollow-bulb obturator prosthesis was processed from the heat-polymerizing acrylic resin using conventional laboratory procedures [Figure 8]. The finished prosthesis was inserted in the patient and checked for any premature occlusal contacts, and necessary adjustments were done. The prosthesis was sterilized in 2% glutaraldehyde solution and delivered to the patient [Figure 9]a and [Figure 9]b.
Figure 7: Impression of the palatal defect

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Figure 8: Final prosthesis

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Figure 9: (a and b) Postoperative intraoral view

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Post insertion instructions were given to the patient emphasizing strictly on the home protocol for hygiene maintenance of both the oral cavity and the prosthesis [Figure 10]. Recall visits were scheduled after 24 h followed by 1 week, 1 month, 3 months and later 6 months after insertion of the prosthesis. The patient was very much satisfied after the placement of the prosthesis which improved esthetics, mastication, swallowing, and speech intelligibility.
Figure 10: Postoperative extraoral view

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   Discussion Top


The rehabilitation of patients with cleft lip and palate often requires a complex multidisciplinary approach and long-term involvement.[9] The design of esthetic and functional dental prosthesis for rehabilitation of cleft lip and palate patients is directly related to the extent of malformations and resulting dysfunction.[10] Numerous prosthetic options are available from no intervention to the use of various forms of conventional or implant supported fixed and/or removable prosthesis.[9] The final treatment plan varies depending on patient psychology, cleft position, maxillomandibular relationship, the presence of remaining teeth, dental, periodontal and bone condition, extent and position of bone grafts, speech and swallowing difficulties, cosmetic deformities, maxillary collapse, age, and financial status.[11]

The rehabilitative and prosthetic management of individuals with cleft lip and palate is one of the final treatment stages, after growth completion, orthodontic, and surgical treatments.[12] Achieving the optimal outcome for patients often require a combination of fixed and removable prostheses in conjunction with other dental and medical treatment.[13]

In the present case, defect was located in the palate extending to the alveolar ridge and labial vestibule with missing maxillary anterior teeth which clearly affected patient's deglutition and speech. The patient was rehabilitated with an FDP and an attachment retained gingival veneer to mask the labial vestibular defect and a cast partial hollow-bulb obturator for improved nasal resonance and prevention of fluid leakage.

Before starting with the prosthetic treatment, it is mandatory to maintain the health of remaining hard tissue and soft tissues. Extraction of grossly decayed teeth and full mouth supra gingival and subgingival scaling was performed for the patient before impression making.

FDPs represent a good option for prosthetic rehabilitation of cleft lip and palate patients with missing maxillary anterior teeth, especially when alveolar bone grafts have failed contraindicating implant placement.[12] Moreover, a multiunit FDP serve to splint the tooth across the cleft area thus enhancing functional loading and esthetics.[3] Maxillary anterior segment of the present case has been restored with a six unit metal ceramic FDP. Unfortunately, the use of a multi-unit FDP may increase the difficulty in oral hygiene maintenance in cleft patient. In this case, the extended embrasures around the abutment adjacent to the remaining fistula covered by removable attachment retained gingival veneer facilitates hygiene maintenance compared with conventional FDP.[14] A diagnostic wax-up performed before the onset of procedures helped to visualize the areas to be restored and the amount of tooth reduction.[12] To compensate for space between right lateral and central incisor due to the alveolar defect, an additional pontic similar to lateral incisor was planned to maintain symmetry and to enhance esthetics. Since the level of gingival margins of adjacent abutments was not equal, gingival porcelain was added to the final prosthesis to improve esthetics.[9]

Another common problem in cleft lip and palate patients is deficient lip support. Removable prostheses are often preferred for cases with the severe bone loss when the cleft needs to be blocked. Unesthetic clasps, functional instability, and interferences to speech are often treated as major disadvantages of removable partial denture treatment. In this case, the residual alveolar defect and deficient lip support were restored with an extracoronal attachment retained gingival veneer which improved not only esthetics and function but also enabled the patient to maintain oral hygiene.[15]

The residual palatal defect of the present case has been rehabilitated with a cast partial hollow-bulb obturator. It was planned to use a complete palate major connector with cast retainers on premolars and molars adjacent to the edentulous space for better retention, support, and stability from the palate and also to improve the antirotational property of the prosthesis. Moreover, the thermal conductivity of metal made it sensitive to temperature changes that improved the functional acceptance of the prosthesis.[12] A hollow-bulb design for obturator was chosen to reduce the bulk of the prosthesis which not only made it lightweight but also provided resonance to sound, improving speech, thus more comfortable for the patient.[16]


   Conclusion Top


Careful treatment planning, good experience, and creativity and team approach are needed to restore proper esthetics and function for adult cleft lip and palate patients. A well-planned prosthetic therapy will result in satisfactory function and esthetics, providing alleviation of deformities in patients with lost anterior dentition along with soft tissue and hard tissue loss. The combined removable and fixed prosthodontic care provided successful results and improved the quality of life for this patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Vojvodic D, Jerolimov P. The cleft palate patient: A challenge for prosthetic rehabilitation – Clinical report. Quintessence Int 2001;32:521-4.  Back to cited text no. 1
    
2.
Strickland F, Psillakis JJ, Grbic JT, Wright RF. Prosthodontic rehabilitation of the adult cleft patient: A case report. Columbia Dent Rev 2004;9:1-9.  Back to cited text no. 2
    
3.
Bavbek AB, Culhaoglu1 AK. An illusionary prosthetic design for a unilateral cleft palate patient. European Journal of General Dentistry 2014;3:71-4.  Back to cited text no. 3
    
4.
Freitas JA, das Neves LT, de Almeida AL, Garib DG, Trindade-Suedam IK, Yaedú RY, et al. Rehabilitative treatment of cleft lip and palate: Experience of the hospital for rehabilitation of craniofacial anomalies/USP (HRAC/USP) – Part 1: Overall aspects. J Appl Oral Sci 2012;20:9-15.  Back to cited text no. 4
    
5.
Moore D, McCord JF. Prosthetic dentistry and the unilateral cleft lip and palate patient. The last 30 years. A review of the prosthodontic literature in respect of treatment options. Eur J Prosthodont Restor Dent 2004;12:70-4.  Back to cited text no. 5
    
6.
Freitas JA, Garib DG, Oliveira M, Lauris Rde C, Almeida AL, Neves LT, et al. Rehabilitative treatment of cleft lip and palate: Experience of the hospital for rehabilitation of craniofacial anomalies-USP (HRAC-USP) – Part 2: Pediatric dentistry and orthodontics. J Appl Oral Sci 2012;20:268-81.  Back to cited text no. 6
    
7.
Acar O, Kaya B, Saka M, Yuzugullu B. Prosthodontic rehabilitation of cleft lip and palate patients using conventional methods: A case series. Int J Prosthodont Restor Dent 2013;3:120-4.  Back to cited text no. 7
    
8.
Mazaheri M. Indications and contraindications for prosthetic speech appliances in cleft palate. Plast Reconstr Surg Transplant Bull 1962;30:663-9.  Back to cited text no. 8
    
9.
Deniz ŞT, Ozkan P, Çelik E. All-ceramic fixed partial denture for cleft lip and palate patient: A case report. Clin Dent Res 2014;38:42-7.  Back to cited text no. 9
    
10.
Destruhaut F, Pomar P, Esclassan R, Rignon-Bret C. Decision making for residual palatoalveolar cleft defects: A new classification. Int J Prosthodont 2015;28:167-8.  Back to cited text no. 10
    
11.
Papi P, Giardino R, Silvestri A, Di Carlo S, Cascone P, Pompa G. Conventional prosthetic rehabilitation of cleft lip and palate patients: Our experience. Senses Sci 2015;2:36-9.  Back to cited text no. 11
    
12.
Freitas JA, Almeida AL, Soares S, Neves LT, Garib DG, Trindade-Suedam IK, et al. Rehabilitative treatment of cleft lip and palate: Experience of the hospital for rehabilitation of craniofacial anomalies/USP (HRAC/USP) – Part 4: Oral rehabilitation. J Appl Oral Sci 2013;21:284-92.  Back to cited text no. 12
    
13.
Wiens J, Wiens R, Taylor T. Psychological management of the maxillofacial prosthetic patient. In: Taylor TD, editor. Clinical Maxillofacial Prosthetics. Chicago: Quintessence; 2000. p. 1-13.  Back to cited text no. 13
    
14.
Wolford LM, Stevao EL. Correction of jaw deformities in patients with cleft lip and palate. Proc (Bayl Univ Med Cent) 2002;15:250-4.  Back to cited text no. 14
    
15.
Palmeiro MR, Piffer CS, Brunetto VM, Maccari PC, Shinkai RS. Maxillary rehabilitation using a removable partial denture with attachments in a cleft lip and palate patient: A clinical report. J Prosthodont 2015;24:250-3.  Back to cited text no. 15
    
16.
Manikanatan NS, Balakrishnan D. Hollowbulb obturator with cast retainers: A case report. J Int Oral Health 2013;5:116-9.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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