Esthetic and Functional Balance - a Clinical Rehabiltation Approach on Two Post Cleft Palate Surgery Patients

Abstract

Management of patients with cleft lip and cleft palate is always very challenging for medical and dental practitioners. The main aim while treating such patients are to restore the esthetics and functions back to normal, which may not be possible in every case, because of extensive resection of structures in the maxilla and the biomechanical limitations regarding the same. In the present case report, two cases of esthetic and functional rehabilitation post cleft lip and palate surgery were discussed. In the first case, an acrylic removable partial denture was opted for rehabilitation. In the second case a fixed partial denture was the treatment plan decided, because here the defect was a closed defect hence there was no escaping of water through the defect and no phonetic abnormalities were present. Cleft lip and palate prosthetic rehabilitation is very challenging aspect in prosthodontics, but the success of any such rehabilitation always depends on how well the operator manages the balance between function and esthetics by giving consideration to patient’s psychological aspects.

Key Words:Cleft lip and cleft palate, Obturator,Removable prosthesis.

INTRODUCTION

Management of patients with cleft lip and cleft palate is always very challenging for medical and dental practitioners. The main aim while treating such patients are to restore the esthetics and functions back to normal, which may not be possible in every case, because of extensive resection of structures in the maxilla and the biomechanical limitations regarding the same. Patients with cleft palate may not be regular cases in general dental practice. However, this is a frequent congenital anomaly; 1 in every 800 live births results in a cleft lip and palate. The cause of cleft lip and palate is not known, but possible causes are malnutrition and irradiation during pregnancy, psychic stress, teratogenic agents, infectious agents (viruses), and inheritance 1. Treating such patients with psychosocial problems are the most challenging part both clinically and technically. These patients were extremely concerned about their appearance and may develop coping mechanisms to reduce social interaction and avoid scrutiny, including teasing, belittling, and other negative social contacts. These anomalies include but are not limited to decreased vertical dimension of occlusion, decreased facial support, temporomandibular joint symptoms, lack of functional occlusion, altered speech, poor esthetics, teeth sensitivity due to abnormal wear and abrasion, lack of a normal smile line, and altered anatomy in the lower third of the face. These patients often require a combination of dental and medical specialists to improve these functional and esthetic problems. Maxillofacial prosthodontic treatment offers improvement in appearance, function, and health of patients with congenital and craniofacial defects 2.Missing anterior teeth are very common in most of the cases of cleft defects, in that lateral incisor are the most in number. In such cases the bone adjacent to these structures will be also weak to support functional load 3. A removable prosthesis will be the choice in such cases because of the adequate support it provide for the soft tissue, fullness and lip support for esthetics and adequate obturation of the defect. Recent improvements in both surgical and orthodontical procedures for maxillary defects has decreased the role of a maxillofacial prosthodontist in such cases, still patients with post operative deficient ridge and esthetics demand are always challenging. Early intervention of surgical techniques can reduce the extent of maxillary defects to a greater scale, where a fixed prosthesis can also provide adequate support and esthetics 4.

CASE REPORT 1

A 29 years old female patient reported to the department of prosthodontics, referred by department of oral and maxillofacial surgery, post a cleft palate and lip surgery for esthetic and functional rehabilitation. On primary examination a classVI maxillary defect (Armany classification) 5 was present, which involves anterior maxillary region. On examination history, patient had underwent cleft lip and palate surgery one year back and also underwent an orthognathic surgery of bilateral sagittal split osteotomy six months before present treatment. The maxillary defect involve the hard palate and premaxillary area with 16 15 11 23 24 26 teeth present in the maxillary arch, in which 11 had grade 1 mobility. In the lower arch 37 36 34 33 32 31 42 43 44 46 47 teeth were present, in which 32 31 42 were periodontally compromised and had poor prognosis. (Fig-1)

Fig 1: Maxillary arch defect and mandibular arch

The chief complaint of the patient was escaping of fluid through the defect to nasal cavity while drinking any liquid. A treatment plan was planned, for upper arch with an acrylic removable partial denture obturator (RPD Obturator). The 11 tooth was earlier planned to extract, but because of satisfactory prognosis after oral prophylaxis, the tooth was retained in order to maintain the profile of the patient by preventing the bone loss following extraction. For the lower arch 32 31 and 42 were planned for extraction because of poor prognosis and decided to rehabilitate with six unit Fixed partial denture. Primary impressions were made out of Alginate. In the maxillary arch a gauze piece was kept with its end kept outside the tray to retrieve the impression. Boarder moulding was done and secondary impression was made out of elastomeric impression material (Putty light body) and picked up with alginate. The cast was poured with typeIII dental stone. (Fig-2)

Fig 2: Master cast

A Facebow transfer was done and the casts were mounted onto a semi adjustable articulator (Whipmix 3000 series). The maxillary cast defect was then blocked out at undercut region and a denture base was made using cold cure acrylic resin. Maxillary occlusal rims were then made and jaw relation was recorded. After teeth arrangement denture try in was carried out, and on the same day, tooth preparation was done for 11 tooth and temporization was done. The RPD obturator was fabricated conventionally in heat cure acrylic resin. Final insertion and 11 single crown fit in was done on the same day of fit in of obturator(Fig 3) and the patient was sent to the department of oral surgery for extraction of 32 31 and 42 teeth

Fig 3: Completed obturator prosthesis and mandibular arch rehabilitation

After the completion of healing tooth preparation was done on 33 43 and 44, and six unit bridge was fabricated and cemented on mandibular anterior region. On the completion of the planned treatment, patient complaints about poor occlusion in mandibular posteriors. This occlusal imbalance was because of the previous surgery done on the mandible, which was explained to the patient and convinced her for a lower posterior occlusal rehabilitation using Fixed partial denture. The lower posteriors were prepared, facebow transfer was done and the casts were mounted on to an articulator in maximum intercuspation position. The bridge was fabricated and cemented onto the lower posteriors for achieving occlusal balance in MI position. (Fig 3)

Fig 4: Case 1, preoperative and post operative photographs

CASE REPORT 2

A 32 year old female patient was referred to dept. of prosthodontics for esthetic rehabilitation, post cleft lip and palate surgery, from the dept. of oral and maxillofacial surgery. On primary examination, in the maxillary arch 17 16 14 11 21 25 26 27 teeth were present and on the mandibular arch all the teeth were present. In this case the defect was a closed defect, and the patient did not encounter any difficulty in function other than problem with anterior esthetics.

An anterior seven unit bridge was planned. Tooth preparation was done on 14 11 21 and 25 teeth (Fig 5) , facebow transfer was done and the casts were mounted on a semi adjustable articulator for fabrication of metal ceramic restoration. After fabrication of metal framework a metal try in was done (Fig 5). The next appointment the ceramic facing prosthesis was cemented.

Fig 6: Case 2, preoperative and postoperative photographs

DISCUSSION

Cleft lip and palate defect is a very common maxillofacial defect, which has been always challenging for a prosthodontist to rehabilitate such cases. The major goal of any operator therefore to achieve maximum stability, support and retention without compromising the function and esthetics. In the present case report, two cases of esthetic and functional rehabilitation post cleft lip and palate surgery were discussed. In the first case, an acrylic removable partial denture was opted for rehabilitation. This was decided because of the patient does not want to go for any more surgical treatment such as implant placement and surgical defect closure because of previous surgeries carried out in both arches. In maxillary arch surgery had done for cleft lip and palate defect and in the mandible a bilateral sagittal split osteotomy was performed as an orthognathic treatment plan to reduce mandibular prognathism. Hence the acrylic removable denture was the choice of treatment for short time period. Patients with cleft lip and palate have shown extensive periodontal problems as compared to general population mainly on the anterior teeth. Only a careful planning of prosthesis and meticulous oral hygiene is a key to achieve optimum esthetics and function 6. A Removable partial denture obturator was opted for the first case because of the following advantages of this treatment over others, such as easier oral hygiene maintenance, providing good lip support in case of severe alveolar ridge resorption and reduced time for treatment, and also because of patient’s psychological problems to undergo further treatment modalities with implant placement and bone grafting procedures 7.

In the second case a fixed partial denture was the treatment plan decided, because here the defect was a closed defect hence there was no escaping of water through the defect and no phonetic abnormalities were present. Congenitally missing teeth on the maxillary anterior section is a very common scenario. In most of these cases lateral incisor were missing or affected frequently, followed by canines and central incisors. The bone support adjacent to cleft was always compromise, but if adequately supported two or more teeth are present on the affected area can receive a fixed partial denture 8. Several studies were done on maxillary obturator designs and their significance in different cases. When a defect is present, the major goal should be always to attain maximum function as compared to esthetics with removable partial dentures, and those with good support and adjacent teeth should restored with fixed partial dentures 2. In the future evolutionary process of rehabilitating maxillary defects, the involvement of the combination of surgical and prosthodontic reconstruction with microvascular surgical techniques and dental implants are more likely to replace the conventional removable prosthesis. But these removable prosthesis were still can’t be completely eliminated because of the comfort, esthetics and hygiene, which is very much needed in the defect site can be well maintained 9.

CONCLUSION

Cleft lip and palate prosthetic rehabilitation is very challenging aspect in prosthodontics. A removable prosthesis is always preferred over a fixed prosthesis were the defect is large and has to close prosthetically for adequate function. But the success of any such rehabilitation always depends on how well the operator manages the balance between function and esthetics by giving consideration to patient’s psychological aspects.

REFERENCES