Journal of Interdisciplinary Dentistry

CASE REPORT
Year
: 2022  |  Volume : 12  |  Issue : 1  |  Page : 41--46

Conservative approaches in prosthodontic management of cleft lip and palate patients


Swagata Deb, Surjargha Mukherjee, Piyush Dongre, Tapan Kumar Giri 
 Department of Prosthodontics and Crown and Bridge, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Correspondence Address:
Dr. Swagata Deb
Villa No. 151, Ganpati Enclave, Dabwali Road, Bathinda - 151 001, Punjab
India

Abstract

The goals of prosthodontic management of patients with cleft lip and palate (CLP) are the restoration of esthetics and improvement of speech and occlusion. Deficiency of bone volume, soft-tissue excess, or presence of oronasal fistula complicates the treatment planning. Though dental implants present a viable treatment option to replace missing teeth in the cleft region, the need for bone augmentation and surgical morbidity limits its application in some patients. A combination of fixed dental prosthesis, resin bonded bridges, removable prosthesis, and overdentures allows conservative management of such patients without causing further morbidity. This clinical report illustrates two patients with CLP managed with a resin-bonded Maryland Bridge and a tooth-supported overdenture.



How to cite this article:
Deb S, Mukherjee S, Dongre P, Giri TK. Conservative approaches in prosthodontic management of cleft lip and palate patients.J Interdiscip Dentistry 2022;12:41-46


How to cite this URL:
Deb S, Mukherjee S, Dongre P, Giri TK. Conservative approaches in prosthodontic management of cleft lip and palate patients. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Aug 14 ];12:41-46
Available from: https://www.jidonline.com/text.asp?2022/12/1/41/344462


Full Text



 Clinical Relevance to Interdisciplinary Dentistry



Interdisciplinary approach between surgery, orthodontics, periodontics, prosthodontics, and speech therapy is essential in the successful management of cleft lip and cleft palate patientsEsthetic and functional rehabilitation is possible for patients of cleft lip and palate with less invasive prosthodontic treatments.

 Introduction



Cleft lip and palate (CLP), the most common congenital disorder of oral stomatognathic structures, can be managed with a prosthodontic approach but is often a very challenging process due to varied presentations of such patients depending on the age, the extent of the defect, and previous treatment that had been attempted.[1],[2],[3],[4] The prosthodontic treatment is directed toward the restoration of lost tissues, function, and esthetics. In these patients, the maxilla is usually hypoplastic and associated with missing teeth. An excessive amount of scar tissues and inflexibility of the upper lip causes an esthetic concern and difficulty in maintaining oral hygiene. The attached gingiva is deficient around the cleft region, leading to less resistance to inflammation. Often, a poor periodontal status along with an alveolar ridge defect adjacent to the existing dentition is observed in CLP patients. This situation is worsened with the lack of proper oral hygiene, leading to a niche for the accumulation of plaque, chronic gingivitis, and further loss of bone support. Caries is more commonly observed due to crowded, malaligned, and hypoplasic teeth present in cleft patients. Despite repeated surgical attempts, often an oronasal fistula is present. In such patients, a serious consideration to maintain the health of the soft tissues should be provided besides planning for a stable, retentive, and well-supported prosthesis. Definitive prosthodontic care is indicated usually after early adolescence when the growth of bone and teeth is completed and a gamut of early treatment has been finished.

This article attempts to describe conservative modalities of treatment for patients with CLP in two different clinical scenarios.

 Case Reports



First case report

A 55-year-old male patient reported to the department of prosthodontics with the chief complaint of ill-fitting upper denture. Patient history revealed the presence of cleft lip and palatal defect which had been surgically corrected in childhood. Premaxilla was absent in this patient and on the posterior aspect of the hard palate, a band of scar tissue was observed [Figure 1]. On examination, the upper right first and second premolar, upper left canine, first premolar and second premolar, and lower left second molar were found to be carious and pulpally affected [Figure 2]. The existing maxillary overdenture was supported by bare teeth as abutments and obturated the oronasal communication in the premaxilla. Denture acrylic teeth in the posterior region were found to be abraded [Figure 3]. After considering the oral hygiene status, and conditions of the abutments in the maxilla, a tooth-supported overdenture with short coping was planned following root canal treatment of the pulpally involved teeth. The patient was informed about the treatment plan and consent was obtained.{Figure 1}{Figure 2}{Figure 3}

Procedure

A diagnostic impression of the maxillary and the mandibular arch was recorded with an irreversible hydrocolloid impression material (DPI, Algitex, India). Root canal treatment was completed for upper right first and second premolar, upper left canine, first premolar and second premolar, and lower left second molar [Figure 4]. Maxillary right first and second premolar and left canine, first premolar, and second premolar teeth were prepared for short coping. After tooth preparation, an impression was recorded by double-stage double-mix technique using polyvinyl siloxane impression material in putty (Dentsply, Aquasil, USA) and light body (3M ESPE, Express XT, Germany) consistency [Figure 5]. Splinted metal copings were cemented with glass-ionomer luting cement (Voco, Meron, Germany) [Figure 6]. After cementation, another set of impression was taken and a working cast was fabricated. An acrylic denture base was fabricated with proper fit and extension, and border molding was performed using a low-fusing impression compound (DPI, Pinnacle tracing sticks, India). Silicone adhesive (Zhermack, Universal Tray Adhesive, Italy) was applied on the low-fusing impression compound and the final impression was recorded with light body silicone impression material (Dentsply, Reprosil, USA). The record base was fabricated and an occlusal record rim was made to record jaw relation following the proper vertical dimension, esthetics, and phonetics, and casts were mounted in the articulator. The tooth setup was completed and try-in was done to evaluate function and esthetics. The final finished and polished maxillary overdenture was delivered to the patient and oral hygiene instructions were given [Figure 7]. On the 7th day, a postinsertion follow-up was done to evaluate for retention, oronasal seal, occlusion, and patient satisfaction. Hypernasality decreased due to closure of the oronasal communication with the prosthesis extension [Figure 8]. Replacement of the deficient palatal tissue and teeth enhanced pronunciation of linguopalatal sounds. Subsequent follow-ups were done after 6 months and 1 year and no adverse events were observed.{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}

Second case report

A 21-year-old girl presented to the department of prosthodontics to get her upper front missing tooth replaced. The patient had a history of upper cleft lip repair surgery. On examination, an excessive amount of soft tissue was observed on the inner aspect of the upper lip and the maxillary left lateral incisor was missing [Figure 9]. The adjacent central incisor and canine teeth were periodontally weakened with Grade I mobility. A definitive prosthesis with a fixed bridge was not possible in this patient due to the already-weakened abutment. An implant replacement of the missing lateral incisor could not be planned due to the deficient bone in the alveolar cleft site. The patient did not either wish to wear a removable prosthesis, so a conservative treatment plan using Maryland bridge was planned to replace the missing tooth and restore esthetics.{Figure 9}

Procedure

After recording diagnostic impression and assessment of the defect site, smile line, and occlusal contacts, the palatal aspects of the adjacent central incisor and canine were minimally prepared for fabrication of the Maryland bridge [Figure 10]. A metal try-in was done to check for the Pontic fit and margin and occlusal contacts with the opposing dentition [Figure 11]. The final prosthesis was delivered after ceramization [Figure 12]. Heavy occlusal contacts were avoided on the Pontic during protrusive and lateral movements of the mandible [Figure 13]. Six-month follow-up was done for the patient, occlusion was evaluated, and oral hygiene measures were reinforced. The patient was advised to use dental floss, inter proximal brushes to clean the pontic area, and fluoride-containing dentifrices and mouthwashes. A professional fluoride application was also planned for the future visit.{Figure 10}{Figure 11}{Figure 12}{Figure 13}

 Discussion



Prosthodontic management of CLP patients encompasses a variety of treatment possibilities including fixed partial dentures (crowns and bridges, Maryland bridge), removable dentures (conventional cast partial overdentures and complete dentures), precision prostheses (appliances with bars, splints, and telescopic retainers), and implants.[5]

The retention and stability of a removable prosthesis are often affected in cleft palate patients. Dental implants can enhance the retention, stability, and occlusal function of the prosthesis.[6] Though before implant placement bone grafting is usually required in CLP patients to close the alveolar cleft, sometimes grafting may not be successful due to the need of high volume of bone required for grafting the inappropriate labial cortical bone contour, poor quality of bone, and proximity to the nasal cavity and maxillary sinuses.[7]

In addition, following the surgery for the CLP, an oronasal communication many a time remains in the palate, which causes a problem in chewing, causes a problem in phonation, and it needs to be obturated.

In the first case, we used a tooth-supported acrylic overdenture to restore the functionality for the patients. An acrylic denture base was chosen over a metal denture base considering the presence of a band of contracted scar tissue in the palatal area and the need for future relining of the prosthesis. The other treatment options that can be considered in situations like this are a removable cast partial denture, attachments retained or telescopic overdenture, or a complete denture. Grossly carious abutment teeth along with a reduction in clinical crown height and poor oral hygiene rendered the treatment consideration for clasp-retained or attachment-retained partial denture to be less favorable in this patient. The swing-lock attachment system is another option to retain a maxillary superstructure, but the design does not allow easy cleaning.[8] The use of overdenture is advantageous with respect to complete denture as it can preserve bone and proprioception at the same time, providing the needed retention and support to the prosthesis. The demerits of metal coping retained overdenture are retention of biofilm and accumulation of plaque under the acrylic denture base and around the abutment teeth, which may increase the risk of abutment caries and periodontitis. This can be prevented by meticulous oral hygiene advice to the patient, denture hygiene maintenance, and regular recall. In this patient, the selected prosthesis design fulfilled our goal of achieving a functional and esthetic balance that is less complex, affordable, and easy to maintain.

In our second patient, we fabricated an adhesively retained Maryland bridge for the replacement of the missing lateral incisor because of abutment mobility. The demerits of the metal-framed Maryland bridge are debonding (21%), caries (7%), and grayish discoloration (18%), making it objectionable in the anterior region.[9] Debonding of Maryland bridge particularly in cleft patients has been observed more with the mobility of the abutment teeth adjacent to the cleft.[5] As in this case, the abutment teeth required no restoration and to preserve tooth structure, a resin-bonded fixed partial denture was used till a more definitive prosthetic planning could be obtained considering the patient's age and the possibility of the future grafting of the cleft.

 Conclusion



Achieving a functional occlusion and creating an acceptable esthetic is often very challenging in patients with CLP. The two clinical reports described here focused on conservative management of patients with CLP with acrylic overdenture and a resin-boded Maryland bridge. In both these patients, finances were limited and a simple prosthesis that allowed easy care and maintenance was imperative.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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