Prosthodontics

The cleft palate patient: A challenge for prosthetic rehabilitationClinical 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 such palienls requires good planning that takes into account ail remaining teeth and roots, deformation ot maxillary segments, residuai palatal defects, and the disproportion between the maxiilary and mandibular 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, phonation, 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 words: cleft palate, prosthodontic reh^ilifation, roof coping, telescope crown

lthough cleft palate patients aie not regularly seen in 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 cleft lip and/or palate.' Cleft palate/lip etiology is stiJl not clarified, but possible causes are malnutrition and iiradiatioii during pregnancy, psychic stress, teratogenic agents, infectious agents (vinises), and heritage (one third to one half of cleft palate/lip patients have previous appearances of this anomaly in their family). Between the 21s and 31st days of intratiterine ufe, five mesenchyme processes covered with ectoderm are being developed. Ectodermal furrows separate these processes, which bound the stomodeum, the future oral cavity. The processes grow with the swelling of mesenchyme so that their epithelial sheet is being disintegrated while the mesenchyme of one structure fuses with the mesenchyme of another. Ectodermai furrows obliterate, and the processes are joined together. In cases in which the obliteration of the furrows does not occur, it leads to congenital cleft up and/or paiate.^

'Assistant Professor. Departmenl of Fixed Prosthodontics, School ot Dentistry, University of Zagreb, Croatia, 'Professor and Vice Dean, School of Dentistry. Department of Removadle Prosthodontics. University ol Zag re 0, Croatia. Reprinl requests: Dr Denis Vo|vodic. Clinical Hosprtal "Dubrava." Clinical Department for Prosthodontics. School of Dentistry, Llniversrty ot Zagreb, Avenija G. Suska 6,10000 Zagreb, Croatia. Fax: 385-f-286-4-248.

Maxillary processes first merge with the lateral nasal swelling (the naso-optical furrow that develops in the nasolacrimal ductus) and then with the medial nasal swelling,'-^ Together, they create the primary palate at 6 weeks, which starts to separate the oral cavity from the nasal cavity.' Joining of the palatal shelves begins at 10 weeks, after the soft tissue has fused, and lasts until 14 weeks, when bone support is established, thus completing the separation of the oral cavity from the nasal cavity.'-^ Morphologic variations of the clefts are so large that it can be said that every cleft is a unique one. For the rehabilitation of such a complex problem, it Is obvious that a team of different medical and dental specialists is needed. The required specialists from dentai fields are orthodontist, pedodontist, and prosthodontist. Orthodontic therapy takes place before (he surgical treatment to assist the surgeons'; the orthodontist's task is to reduce the gap between the segments, to stimulate the palatal bone growth,^'-^ to correct the malformations of the alveolarridge,^as well as to ease and improve the feeding of the child with the cleft.'-^ A pedodontist treats the remaining teeth {frequent hypodontia),'" especially those with enamel hjipoplasia as a consequence of surgical trauma. Surgical treatment 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. 521

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Surgical treatment bas a negative effect on maxillary growtb because of scar tisstte developtnent. As more scar tissue develops, tbe consequences become greater- Matiy autbors attest to severe maxillary deficiency in all dimensions," dramatic effects on maxillary growth (in cases in which the bone grafting to tbe cleft area is done early),'- an often concave facial skeleton profile in adttlthood," and severe effects on the dental arches (contraction in the sagittal and transverse planes) if the scars run close to the teeth"*; Ross'^ described tbe scar tissue effect as maxillary ankylosisBecause of tbe aforementioned reasons, repeated operafions more often increase tbe deformations (new scar tissue) rather than further the correction of the condition after the first treatment; a reducfion in the number of operations is recommended. General clinical experience reveals tbat the sooner tbe surgical treatment is performed, the more drastic the scar tissue effect becomes. Tberefore, some tberapists suggest delay of tbe bard palate surgery (excluding early bone grafting) unfil the child is 8 to 10 years old to provide sufficient time for tbe growtb and development of tbe maxilla.'*'" In adulthood, the task of the prosthodontist is to restore the lost teeth and parts of the alveolar ridge to obtain function, esthetics, and alleviate the deformifies as much as possible.
CLINICAL REPORT

A 23-year-old female patient with a surgically treated bilateral cleft lip and palate was examined in the Clinical Department tor Prosthodontics at the School of Dentistry, University of Zagreb, Croatia. Examination revealed persistent communication with the nasal cavity at the hard palate, a so-called residual palatal defect with dimensions of 2 mm X 3 mm, through which liquids periodically entered the nasal cavity while drinking- Chewing abilities and esthetics were very poor because of the lost teeth and maxillary deficiency. The whole premaxilla was practically missing, including all maxillary incisors and the right canine- The maxillary left canine, second premolar, and first molar had heen endodontically treated but had severe crown destruction. Other remaining teeth had amalgam fillings without secondary decay (Fig 1). The vertical dimension of occlusion remained constant and normal, and it was 3 mm above rest posifion,'* but witb a cross bite hecause of the maxillary deficiency (Fig 2). The roots of tbe nonvital teetb were prepared, and individual cast-metal posts and cores were made for tbe maxillary second premolar and the first molar- A heavy-body silicone impression witb Degufiex impres-

sion material (Degussa) was made. Retraction cords were placed in tbe gingival sulci of tbe prepared teeth and removed after 4 minutes. A small piece of gauze coated witb petroleum jelly was placed over the residual palatal defect, and a light-body impression material (Xantopren L, Heraeus Kulzer) was put over the prepared teeth with a syringe (Fig 3). Tbe beavy-body impression was covered witb a ligbt-body material, and the tray was piaced in tbe moutb. Tbe gauze coated witb petroleum jelly was put over tbe residual palatal defect so that the light-body silicone impression material could not enter tbe nasal cavity (Fig 4). If some of the light-body silicone material entered tbe residual palatal defect, its pedicle could breaii during tbe removal of the impression from the mouth, causing probierns in removing tbe retained part. For tbe root of tbe maxillary left canine, a coping with intraradicular retention was made with a Dalla Bona stud attachment (Servo Dental). On all maxillary premolars, telescope crowns were placed, and a cone crown was designed for the maxillary right first molar (Fig 5). This solution was chosen to provide good retention and to ensure that the patient would enjoy a better feeling of security,'' esthetics with greater freedom for correct tooth positioning, and more favorable loading conditions for tbe abuttnent roots^"'^' with regard to the disproportion hetween tbe two alveolar ridges. All metal parts were cast from a gold-platinum alloy 18-1-8 (Precious Metals Refinery) to provide durability of the construction parts that would be submitted to friction. The metal basis of the denture was made from Co-Cr alloy (Remanium GM 380, Dentaurum). The palatal part of the prosthesis was used as an obturator to facilitate drinking, disabling the entrance of liquid into the nasal cavity."" Despite the deformities, tbe final reconstructive denture bad safisfactory occlusion and articulation with the natural mandibular teeth (Fig 6),

CONCLUSION

Clefi palate patients with maxillary bone and tootb loss present a significant challenge for prostbefic rehabilitation. In this case, as in any case, the patient desired to improve her mastication, phonation, and esthetics. These results can be best achieved through the judicious use of appropriate treatment modalifies tempered by ciinical experience. For a successful rehabilitation of cleft palate patients, it is indispensable to take care of all teeth and roots (even tbose tbat look unsuitable), because significant hone loss can interfere with or prevent the selection of acceptable implant sites. Consequently,
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Rg 1 Siiijaiion in itie maxiila Deioie prosmeuc eauTieni.

Fig 2

Patents maximum intercuspation.

Fig 3 Placement ot a light-body impression material: gauze coated witti patraleum jelly is piaced over ttie residual paiatai detecL

Fig 4

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

Fig 6 Reconstructive prostnesis in occlusion wah natural mandibuiar teeth.

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inadequate retention of a reconstructive prosthesis can cause difficulties in mastication and communication and can affect esthetics. During prosthetic therapy planning, one should take into consideration the remaining roots and teeth, deformation of maxillary segments, residual palatal defects, as well as the disproportion hetween the maxillary and mandihular alveolar ridges. Experience and creativity are needed to achieve the desired prosthetic rhabilitation. Wellplanned prosthetic therapy wiil result in satisfactory function and esthetics, providing alleviation of the deformities.

REFERENCES 1. Moyers RE. Handbook of Orthodontics, cd 4. Chicago. Year Book Medical, 1988:19-27. 2. Epker BN, Fish LC. Dentofacial Deformities. Integrated Orthodontics and Surgical Correction. St Louis: Mosby, 1986:640-709. 3. Kjaer I. Human prenatal craniofacial development related to brain development under normal and pathologic conditions. 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 orthopedics. Why, when, how. Am J Orthod 1976:69:562-571. 6. Brogan WF, McComb H. The early management of cleft lip and palate deformities. Aust Dent J1973; 18:212-217. 7 Graf-Pinthus B, Bettex M. Long term observation following presurgical orthopedic treatment in complete clefts of the lip and palate. Cleft Palate | 1974;ll:255-260. 8. Holz M. Aims and possibilities of pre and post surgical orthopedic treatment in unilateral and bilateral clefts. Trans Eur Orthod Soc 1973;553-558. 9. Mcliinstry RE, Browning S. Microwave processing of cleft palate orthopedic expansion devices. | Prosfhet Dent 1992; 67:882-886.

10. Hobkirk [A, Brook AH. The management of patients with severe hypodontia. ] Oral Rehabil 1980;7:289-298. 11. Graber TM. Craniofacial morphology in clelt palate and cleft lip deformities. Surg Gynecol Obstef 1949;88:359-369. 12. Friede H, Johansonn B. Adolescent facial morphology of bone-grafted cleft lip and palate patients. Scand ] Plast ReconstrSurg 1982; 16:41-53. 13. Friede H, Pruzanslty S. Long-term effects of premaxillary setback on facial skeletal profile in complete bilateral cleft lip and palate. Cleft Palate ] 1985;22:97-105. 14. Friede H, Persson E-C, Lilja J, Blander A, LohmanderAgerskov A, Soederpalm E. Maxillary dental arch and occlusion in patients with repaired clefts of fhe secondary palate. Scand J Plast Reconstr Surg 1993;27:297-305. 15. Ross RB. The clinical implications of facial growth in cleft lip and palate. Cleft Palate J 1970;7:37-47. 16. lohanson B, Lilja J, Friede H, Moeller M, Lauritzen C. The evolution of the therapeutic approach to eleft lip and palate in Gothenburg. In: Hotz M, ef al (eds]. Early Treatment of Cleft Lip and Palate: Proceedings of the Third international Symposium, Univ of Zurich. 27-29 Sept 1984. Toronto: H Huber, 1986:85-89. 17 Friede H. Abnormal facial growth. Acfa Odontol Scand 1995;53:203-209. 18. Posselt U. Intermaxillary relations. In: SharryJJ (ed). Complete Denture Prosfhodontics. New York: McGraw-Hill, 1962:187-217. 19. Preiskel HW. Precision Attachments in Dentistry, ed 2. St Louis: Mosby, 1973:112-140. 20. Basker RM, Harrison A, Ralph JP, Watson C]. Overdentures in General Denfal Practice, ed 3. London: British Dental Association, 1993:49-65. 21. Siddiqui AA, Toljanic JA. Adaptation to removable prosthesis. I Prosthet Dent 1993;70:283-284. 22. Desiardins RP. Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent 1978;39:424-435. 23. Shimodaira K, Yoshida H, Mizukami M, Funaliobo T Obturator prosthesis conforming to movement of the soft palate. ] Prosthet Dent 1994;71:547-55L

Erratum
In Table 2 of the article "Effect of calcium removal on dentin bond strengths" by Perdigo et al (Quintessence Int 2001;32:142-146), the mean bond strength of Prime&Bond NT applied to an undecalcified dentinal surface (control) should be 23.0 MPa, not 2.3 MPa as published. The author and publisher regret this error.

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