Rehabilitation of Anterior Aesthetic for Patient with Cleft Lip and Palate-a Case Report

INTRODUCTION

Lips form the boundary of the oral orifice. Palate is the partition between oral and nasal cavity. The incidence of cleft lip with or without cleft palate is 1:750 and the incidence of cleft palate alone is 1:2500.¹ Cleft of the lip are more common in males. Possible causes include maternal drug exposure, a syndrome malformation complex or genetic factors. Although both appear to occur sporadically, the presence of susceptibility genes appears important.^2-4

Clefts of the lip and palate (CLP) are commonly encountered congenital anomalies, affecting one in seven hundred live births and often result in severe functional deficiency on the patient’s chewing abilities, appearance and ability to speak.⁵ Generally, they are classified into four major types: cleft lip, cleft palate, unilateral cleft lip and cleft palate (UCLP), and finally bilateral cleft lip and palate (BCLP). A combination of cleft lip and palate is the most common clefting deformity seen. The prevalence of dental anomalies associated with cleft lip and palate is remarkable.⁶ Abnormalities of tooth number, size, morphology, calcification and eruption have been described.

Paranaiba et al demonstrated that patients with unilateral CLP were frequently more affected by dental anomalies than bilateral CLP. It require multidisciplinary treatment planning by surgeons, orthodontists and restorative and a prosthodontists is required for the long-term benefit of this small but challenging group of patients.⁷ This article represents rehabilitation of patient with cleft lip and palate in the anterior aesthetic zone.

CASE REPORT

A 21 year old female patient reported to the department of oral surgery at K.D Dental college 2 year ago and received lip as well as palate surgeries. The patient was then referred to the department of orthodontics for correction of alignment, but due to time restrain the patient discontinued treatment and was referred to the Dept. of prosthodontics for rehabilitation of Anterior esthetics.

Fig. 1 EXTRA- ORAL PREOPERATIVE PROFILE

Intraoral examination showed presence of congenital deciduous maxillary canine and impacted permanent canine but patient was not willing for extraction of the impacted teeth. Fig 2.

Fig.2 INTRAORAL EXAMINATION

TREATMENT PLANNING

The radiographic and clinical analyses showed no bone loss around the abutment teeth, over retained deciduous canines. The right and left central incisors and first and second premolars were prepared to receive a fixed prosthesis.

After tooth preparation patient was refered to the department of oral surgery for immediate extraction of the retained deciduous teeth followed by Immediate provisionalization.(fig 3)

Fig. 3 IMMEDIATE EXTRACTION OF OVER-RETAINED DECIDUOUS 53, 63

Followed by extraction immediate provisionalization was done using luxatemp temporary material. (fig 4). After healing Provisionals were replaced with fixed porcelain fused to metal restoration.

Fig. 4: IMMEDIATE PROVISIONALIZATION

Final cementation of porcelain fused to metal prosthesis were luted with type I glass ionomer cement. The final restorations met both esthetic and functional needs. Patient was happy and satisfied with the aesthetics (fig 5) Intraoral & extraoral postoperative profile.

Fig 5: INTRA-ORAL POSTOPERATIVE PROFILE

EXTRA-ORAL POSTOPERATIVE PROFILE

DISCUSSION

Patients with congenital and craniofacial defect are unique, and oral problems must be evaluated individually to the most ideal treatments.^8,9 When making a decision whether to use fixed or removable partial dentures; defect form, speech and swallowing difficulties, dental abnormalities, cosmetic deformities, maxillary collapse age, and financial status are the factors that form the prosthetic treatment plan.^10-11

Prosthodontic rehabilitation of missing maxillary anterior teeth requires special consideration to restore aesthetics.¹² The importance of oral health and hygiene cannot be ignored. Besides, following surgical repair of the lip and palate, a defect in the alveolar ridge at the edentulous area adjacent to the abutment teeth may remain.^13-14 Destruction type will play an important role in selecting the pontic design. Ridge deformities have been classified into three categories. Class I; loss of faciolingual ridge width with normal apicocoronal height, class II; loss of ridge height with normal width, and class III, loss of both ridge width and height.^15-17

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), fiber-reinforced composite resin-bonded FPD, conventional removable partial denture (RPD) and combination of fixed and removable partial dentures.^8,9 Prosthodontist should make a decision whether to use fixed (conventional or implant supported) or removable partial denture. When a missing tooth is to be replaced, a conventional FPD or implant supported FPD is preferred by the majority of the patients.^18,19 However, there is an important prerequisite for FPDs, that there should be no gross soft tissue deficiency in the alveolar ridge. If there is, it may be possible to augment the ridge with grafts. According to Kantorowitcz, FPDs should be extended as far as second premolar or the first molar to ensure stability.²⁰

Despite recent advances in bone grafting and dental implants for CLPs, conventional prosthodontic rehabilitation remains to be an important aspect in treatment of these patients. Masticatory and speech functions had markedly improved in CLPs patient following treatment as well their psychological state. Longer follow-up periods must be made for further evaluation of these patients in terms of prosthodontic complications which may come up in the future.

REFERENCES