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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 41-43

Occlusal and Aesthetic Rehabilitation of Cleft Lip and Palate Patient- A Case Report


1 Senior Resident, Department of Dentistry, AIIMS, Patna, Bihar, India
2 Private Practitioner, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Sumit Singh
Senior Resident, Dept. of Dentistry, AIIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


The patients suffering from various maxillary defects of palate and lips require a form of definitive treatment after attaining adulthood. These defects affect the patients psychologically giving them negative impact of life, the treatment of these defects with definitive prosthesis will enhance the aesthetics along with occlusal rehabilitation and giving them the confidence they require. This case report describes the rehabilitation of 18yrs old female patient with unilateral cleft palatal defect which is rehabilitated with porcelain fused to metal (PFM) crowns covering the defect and as well providing the confidence the patient required.

Keywords: Occlusal rehabilitation, esthetic, unilateral cleft palate, porcelain fused to metal (PFM)


How to cite this article:
Singh S, Biswas KP, Singh A, Chaturvedi A. Occlusal and Aesthetic Rehabilitation of Cleft Lip and Palate Patient- A Case Report. J Indira Gandhi Inst Med Sci 2018;4:41-3

How to cite this URL:
Singh S, Biswas KP, Singh A, Chaturvedi A. Occlusal and Aesthetic Rehabilitation of Cleft Lip and Palate Patient- A Case Report. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:41-3. Available from: http://www.jigims.co.in/text.asp?2018/4/2/41/302953




  Introduction: Top


Clefts of the lip and palate (CLP) are commonly encountered congenital anomalies, affecting one in seven hundred live births[1] and often result in severe functional deficiency on the patient's chewing abilities, appearance and ability to speak.[2] The restorative dental care and management of cleft lip and palate patients calls for a complex multi-disciplinary approach with long term involvement.[3] These patients eventually require definitive fixed or removable prosthesis for aesthetic and functional demands when they become adults.[4] The maxillary central incisors are often hypoplastic with short roots and are severely malposed.[5] When planning a prosthetic rehabilitation for a patient with congenital abnormalities; lack of teeth, intraoral anatomic deformities, inadequate arch development, and inspection of appropriate occlusal vertical dimension must be taken into consideration.[6] Paranaiba et al[7] demonstrated that patients with unilateral CLP were frequently more affected by dental anomalies than bilateral CLP. The incidence of congenitally missing teeth, especially lateral incisors adjacent to the alveolar cleft is high.[2],[6] There are various treatment modalities of definitive prosthesis for unilateral and bilateral cleft lip and palate patients after completion of orthodontic treatment such as; conventional multi-unit fixed partial denture (FPD), resin composite veneered multi-unit FPD, fiber- reinforced composite resin-bonded FPD, conventional removable partial denture (RPD), RPD with extra coronal attachment and combination of fixed and removable partial dentures.[8] In this case report the management of an alveolar cleft which is being managed by PFM crowns to maintain the esthetics desired by the patient due to economical constraints.


  Case Report: Top


An 18 years old female patient reported to outdoor patient department of Department of Prosthodontics in Vananchal Dental College and Hospital, Garhwa, Jharkhand for the replacement of missing teeth (22) due to the alveolar cleft. On clinical and radiographic (OPG & OCCLUSAL x-ray) [Figure 1] examination confirmed that a repaired unilateral cleft palate and moderate tissue deficiency in the palate. Bone grafting and implant placement were not indicated due to the extent of the defect area in the palate [Figure 2]a, [Figure 3]. There were no food or liquid leakage into the nasal cavity but the extent of hard and soft tissue deficiency influences the aesthetic appearance and phonetics. A Porcelain Fused to metal fixed partial denture was chosen as a definitive restoration since this system has an acceptable marginal fit, adequate function and good esthetic properties. The diagnostic casts were made and a mock preparation followed by wax up was done, the esthetic results were evaluated and patient consent was obtained with the results obtained in mock up. The abutment teeth chosen were both central incisor, right lateral incisor, both canines, and both first premolars. The mesially tilted right central incisor [Figure 2]b was root canal treated as the patient was not willing for orthodontic correction of the tooth. After preparation of these teeth [Figure 3] a pre fabricated tray and two types (light and heavy body) silicone impression material (soft putty, light body) was used. The master cast was transferred to an articulator using an interocclusal record when the molars were in the maximal intercuspal position. We had to use one extra pontic (except the left incisor pontic) to restore the defect area between upper left lateral incisor and canine. The pontic was designed in a modified ridge lap pattern. The pontic was contoured like an upper right canine for the best aesthetic results [Figure 4]. The fittng accuracy of the frameworks was tested in the patient's mouth before the ceramic veneer was applied. The frameworks were evaluated intraorally for accuracy of fit after the addition of veneering ceramic. The gingival margins of the right canine pontic and lateral incisor abutment were not at the same level with the other abutment. To restore the osseous defect gingival porcelain was used to replicate the gingiva. As the gingival margins were not visible in the smile line, the defect on the alveolar ridge was restored by extending the length of the canine pontic, with gingival porcelain. The completed prosthesis was luted with Type I Glass ionomer cement [Figure 5]. The defect area on the alveolar ridge was healthy and aesthetically compatible with the restorations.
Figure 1: Occlusal Radiograph

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Figure 2a: pre-operative view

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Figure 3: Crown Prepration

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Figure 4: Temporisation Done

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Figure 5: Post Operative View

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  Discussion: Top


Adolescent patients with cleft lip and palate present special prosthodontic problems and demand particular attention to aesthetic considerations. Management of such patients should, ideally, begin early and be part of the overall team approach and patient must be instructed to maintain good oral hygiene and dietary advice being given to patients at the outset, and thereafter continually reinforced.[6] Numerous factors affect decisions for the most appropriate restoration.[6] Henry and Tan[9] addressed issues of patient psychology, particularly the age at which patients are receiving prosthetic care. Siebert[10] classified the ridge defects into three categories.

Class I- Loss of faciolingual ridge width with normal apicocoronal height.

Class II- Loss of ridge height with normal width.

Class III- Loss of both ridge width and height.

Authors described the use of multiple unit bridges (6-10 units) to replace missing teeth and stabilize the maxillary arch.[11],[12] This patient had a wide space between left central incisor and canine because of the alveolar defect. Therefore, one more canine pontic was placed to restore this area. The crown for the left canine abutment was fabricated like an upper first premolar to maintain symmetry. During the provisional phase, aesthetics, phonetics, retention and occlusion were assessed. As the gingival margins were not visible in the smile line, the length of the canine was extended with gingival porcelain for the final prosthesis. Thus, the defect on the alveolar ridge could also be restored and the gingival margin of the left canine pontic was at the same level with the other abutment teeth.

Herein, Prosthodontic should make a decision whether to use fixed (conventional or implant supported) or removable partial denture.[13] The circumstances of vertical bone loss at edentulous anterior region, RPDs can hinder severe hygiene problems and deficiencies of labial support contrary to FPDs[14] and can provide good esthetics.[6] In addition it is possible to ensure permanent retention of maxillary arch while hindering arch collapse with RPDs.[15] Despite these advantages, patient satisfaction with RPDs significantly reduces with age.[16] The common objection is that its removable structure accentuates its artificial character.[17] Alternatively osseointegrated implants after secondary bone grafting have provided an invasive treatment approach for cleft lip and palate patients.[18],[19] The use of endosseous implants for CLP patients with grafted alveolar clefts have lots of advantages, especially preservation of tooth structure in healthy adjacent teeth[20] and the prevention of resorption of grafted bone.[21] Secondary bone grafting at the early stage of the mixed dentition posses many benefits, however there is a conflict on timing of bone grafting.[22] Despite various advantages of surgical intervention in cleft lips and palates, conventional prosthetic rehabilitation may be preferred especially in young patients, in whom bone grafting followed by endosseous implants is not a treatment option, because of patients choice or socio-economic constraints.


  Conclusion: Top


Despite, the recent advancement in bone grafting and dental implants for cleft lip and palates, conventional prosthodontic rehabilitation, remains to be an important aspect in treatment of such patients. The treatment plan markedly improved the masticatory, speech functions and also helped to stabilize the psychological state of the patient.



 
  References Top

1.
MA, Coupland AI. Seasonality, incidence, and sex distribution of cleft lip and palate births in trent region, 1973-1982. Cleft Palate J 1988;25:33-37.  Back to cited text no. 1
    
2.
Regezzi JA, Sciubba JJ, Jordan RCK, editors. Oral Pathology, Clinical Pathologic Correlations. St. Louise, Missouri, Elsevier, Saunders: 2003;362-363  Back to cited text no. 2
    
3.
Murat S, Gurbuz A, Genc F. Prosthetic rehabilitation of a patient with bilateral cleft lip and palate using osseointegrated implants and extracoronal resilient attachments: a case report. Cleft Palate Craniofac J 2011; 48: 342-347  Back to cited text no. 3
    
4.
Watanabe I, Kurtz KS, Watanabe E, Yamada M, Yoshida N, Miller AW. Multi-unit fixed partial denture for bilateral cleft palate patient: a clinical report. J Oral Rehabil 2005; 32: 620-622.  Back to cited text no. 4
    
5.
?ule Tu?ba Deniz, Pelin Özkan and Ersan Çelik. All-Ceramic Fixed Partial Denture For Cleft Lip And Palate Patient: A Case Report Clinical Dentistry And Research 2014; 38(1): 42-47  Back to cited text no. 5
    
6.
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;12:70-74  Back to cited text no. 6
    
7.
Paranaiba LM, Coletta RD, Swerts MS, Quintino RP, de Barros LM, Martelli-Junior H. Prevalence of dental anomalies in patients with nonsyndromic cleft lip and/or palate in a Brazilian population. Cleft Palate Craniofac J 2013;50:400-405.  Back to cited text no. 7
    
8.
Ayna E, Basaran EG, Beydemir K. Prosthodontic rehabilitation alternative of patients with cleft lip and palate (CLP): two case reports. Int J Dent 2010;DOI:10.1155/2009/515790.  Back to cited text no. 8
    
9.
Henry PJ, Tan AE. Prosthodontic implications of the adolescent cleft palate patient. Aust Dent J 1985; 30: 104-111.  Back to cited text no. 9
    
10.
Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 1983;4:437-453.  Back to cited text no. 10
    
11.
Gold HO, Pruzansky S. Multiple-abutment fixed partial dentures in maxillofacial prosthetics. J Prosthet Dent 1979; 41: 424-444.  Back to cited text no. 11
    
12.
Carl W. Anterior fixed proshetics for cleft palate patients. Quintessence Int 1984; 15: 721-727.  Back to cited text no. 12
    
13.
Hochman N, Yaffe A, Brin I, Zilberman Y, Ehrlich J. Functional and esthetic rehabilitation of an adolescent cleft lip and palate patient. Quintessence Int 1991; 22: 401-404.  Back to cited text no. 13
    
14.
Preiskel HW. Precision attachments in prosthodontics: the applications of intracoronal and extracoronal attachents. London:Quintessence Publishing Co., Inc. 1984 p.151-154.  Back to cited text no. 14
    
15.
Berkowitz S. Cleft lip and palate: diagnosis and management. Berlin: Springer; 2006:132.  Back to cited text no. 15
    
16.
Koyama S, Sasaki K, Yokoyama M, Sasaki T, Hanawa S. Evaluation of factors affecting the continuing use and patient satisfaction with removable partial dentures over 5 years. J Prosthodont Res 2010;54:97-101.  Back to cited text no. 16
    
17.
Reisberg DJ. Dental and prosthodontic care for patients with cleft or craniofacial conditions. Cleft Palate Craniofac J 2000; 37:534-537.  Back to cited text no. 17
    
18.
Kawakami SY, Horiuchi M, Moriyama S, Oral K. Rehabilitaion of an orthodontic patient with cleft lip and palate and hypodntia using secondary bone grafting, osseointegrated implants, and prosthetic treatment. Cleft Palate Craniofac J 2003;41:279-284.  Back to cited text no. 18
    
19.
Verdi FJ Jr, SLanzi GL, Cohen SR, Powell R. Use of the Branemark implant in the cleft palate patient. Cleft Palate Craniofac J 1991;28:301-303.  Back to cited text no. 19
    
20.
Mish C. Dental Implant Prosthetics. St Louise, Missouri: Elsevier Mosby. 2005;4.  Back to cited text no. 20
    
21.
Kearns G, Perrott DH, Sharma A, Kaban LB, Vargervik K. Placement of endosseous implants in grafted alveolar clefts. Cleft Palate Craniofac J 1997;34:520-525.  Back to cited text no. 21
    
22.
Graber TM, Vanarsdall RL, Vig KWL, editors. Orthodontics: current principles and techniques, 4th ed. St Louis: Elsevier Mosby; 2005.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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