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Cleft Palate

Cleft Palate

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Published by: drreba on Sep 15, 2010
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PROSTHETIC REHABILITATION OF CLEFT PALATE PATIENTS Introduction The cleft lip and palate deformity is a congenital defect of the

middle third of the face, consisting of fissures of the upper lip and or palate. The patient with clefts of the primary and secondary palate presents a complex biologic, sociologic ,and psychologic problems. For the effective treatment of the cleft palate patients, there should be coordinating efforts of numerous specialists from the medical, dental and speech pathology departments. Prosthetic need will vary with each patient from presurgical orthopedic appliances,speech aids,single tooth replacements,multiple tooth replacements,complete dentures with speech aid and prosthetic replacement of the missing facial units. CLEFT PALATE Is defined as a congenital fissure or elongated opening in the soft and\or hard palate Or An opening in hard and/or soft palate due to improper union of the maxillary process and median nasal process during the second month of intra uterine development.


-heredity -infections drugs{phenytoin,barbiturates etc} poor diet hormonal imbalance in first trimester of pregnancy

Classification -Based on the extent of the defect Class I :- cleft lip with cleft alveolus (primary palate) Cass II:- cleft of hard and soft palate (secondary palate)class II :- combination of class I and classII

Veau’s classification(1922) Class I cleft involves only the soft palate Class II :- involve the soft and hard palate but not the alveolus. Class III :- which involves the soft and the hard palate continuing through the alveolus on one side at pre maxillar area. Class IV :-which involves the soft and the hard palates, the cleft continuing through the alveolus on both sides ,leaving a free premaxilla.

PROBLEM ASSOCIATED WITH CLEFT PLATE 1. Feeding problem in infancy due to oronasal communication

Lack of negative pressure necessary for suckling . Nasal regurgitation of food Feeding time is significantly longer and fatigues both baby and parent 2. Defective speech : Inadequate palate function causes Defective speech & hypernasality Patient may recruit abnormal facial and pharcyngeal muscle for speech . Atypical movement pattern of tongue, lips and mandible . 3. Abnormal swallowing patterns : Inadequate separation between the oral and nasal cavities inorder to prevent nasal regurgitation . 4. Recurrent middle ear infections : Due to veloopharayngeal deficiency , middle ear infections are common in cleft palate patients. 5. Abnormal tongue & Jaw – position : Medial –position of the maxillary

segments forces the tongue and jaw to assume a lower position . Abnormal position of the tongue below the teeth stops the vertical development of the maxilla by interfering with normal tooth eruption . There will be compensatory eruption of the mandibular teeth which increases the vertical development and produces an occlusion at highest level than is desirable for aesthetic facial proportions. 6. Protruded pre-maxilla :- seen in bilateral cleft cases . Lip closure is often difficult 7. Associated facial defects : Such as nasal deformity , ear deformity , facial cleft, mid-facial retrusion etc.


Dental problems include constricted upper arch and crosstie, missing teeth

(Commonly lateral incisor ) supernumerary teeth closed bite, severe malocclusion . 10. Socio- psychological, problems : Most patients will have psychological trauma due to poor speech and aesthetics so treatment should also address psychological needs of patients also . Team approach Cleft palate patients presents with a complex biologic, sociologic, and psychologic problems. Best management involves several disciplines, a team approach. Members include. Pediatrician Plastic Surgeon Pedodontist Otolaryngologist Speech pathologist Prosthodontist Geneticits Pediatric psychiatrist and social worker . Diagnosis in cleft palate treatment It in based on the assessment of findings on morphology – and function Treatment of cleft plate patients History :- Bein suggested that first otruration of a cleft palate was by Demosthiscus(384-323 B.C),great Greek Orator, who used to visit seashore in search of properly sized pebbles to till his palatal defect thereby improve his speech.

More current

medical literature credits, Stollerius, Petronius and Pare with

descriptions of prosthesis for obturation of palatal defects in 16th century. Works by snell, stearn, kingsley and sareson in 19th century design. Clinical observation evaluated according to the expected morphology, function & consideration for future growth potential. Methods of Morphological assessment Clinical examination of lip, tongue and jaw position during rest . The movement of mandible from rest position to maximum inter cuspation of teeth. Is observed forward shift with overclosure of the mandible can be noted. Problems of speech :- evaluated by speech pathologist can distinguish errors in language development , articulation, nasal emission ad resonance balance . Principles of treatment It may be useful to identify some of the characteristic of cleft palate patients at various ages and identify which factors support a favourable prognosis . describe current prosthetic

Suckling & swallowing problems : prevented by ,
 A more upright position of infant a bottle with the nipple opening slightly

enlarged .  Gastric tube feeding is sometimes necessary .  A small palatal prosthesis ; feeding plate ca be given In Pierre Robin syndrome (with small tongue & mandible with cleft) small tongues can fall back and block the air way.

A palatal prosthesis that covers the cleft and us extended downward to keep the tongue and jaw forward, is given. Primary lip surgery : is done within the first few months after birth when the infant is thriving .

Lip closure without excessive tension provides, favorable, contour un the pre-maxillary area and narrows the cleft of the patient .

In Bilateral clefts, the traction to facilitate lip closure in clone with various appliances .

After lip closure has been achieved, the position of maxillary segments will move under the influence of the established tension.

 

The pre positioned segments can be maintained Retention appliances & intra alveolar bone grafting procedures .

Primary palate closure:Timing varies from about 18 months to 4 years. Sometimes delayed in wide clefts with lack of available tissue. In this case an interim prosthesis can be given. But the decision is made on an individual basis.

Primary Dentition 

In bilateral cleft, premaxilla is prominent at this age. Main concern is to prevent maxillary incisors from resting infront of the lower lip.

In some cases extraction of malpositioned incisors and allowing some resorption of alveolar process may be necessary.

Lateral incisors may be located in the cleft . These malpositioned teeth should be preserved because they offer support to counteract forces moving the cleft maxillary segment in a media direction.

A palatal fistulae that is sufficiently large to allow fluid loss through the nose or contribute to nasal air escape in speech can be obturated by a simple palatal prosthesis.

Mixed Dentition

Eruption of central incisors into a normal over bite relationship to mandibular teeth is critical.

An edge to edge bite at this time can lead to development of a forward shift and over closure of the mandible.

Judicious grinding of teeth can be done to establish normal relationship of the anterior teeth.

Most common missing tooth is lateral incisors when the cleft affects alveolus supernumerary teeth are extracted if they are not contributing to the bone development in the alveolar process and are of no use for prosthodontic purpose.

Reduced number of teeth in mandible in bicuspid areas may be an advantage in cleft palate treatment.

But if maxillary bicuspids are missing, it will complicate upper arch size.

In this case maxillary molars are moved forward and the size of the mandibular arch should be reduced by extractions if necessary.

Rotation of the maxillary bony segment laterally especially in the anterior part of maxilla is achieved with orthodontic appliances .

Retention is usually accomplished by use of lingual arch wire. Additional movement of cleft segment may be required to keep up with mandibular growth.

Replacement of lateral incisor can be done by cold curing a plastic tooth onto lingual arch wire.

Speech and hearing evaluations and surgical revision of the nose, lip and palate are done depending on the needs of individual patients.

Adolescence The Orthodontic Treatment at adolescence is designed to achieve

Normal position of the maxillary segments Adequate vertical development of maxilla and  Alignment of teeth for efficient occlusion, aesthetics and positioning to permit conservative, prosthodontic replacement of missing teeth.  Consultation between orthodontist and prothodontist is necessary. Additional adjustments of anterior tooth position may be required at about 18 years of age.  After the maxillary segments and canines are brought into maximum favourable position, permanent stabilization of the arch by establishment of bony continuity between the cleft segments can be safely accomplished at 14-16 years.

 Various bone graft procedures are available for stabilization of maxillary segments and support for nasal alae.
 This stabilization of maxillary segment by healing the cleft through new bone

formation allow the prosthodontist to reduce the span of fixed prosthesis, replacing missing teeth.  Without an intact maxilla a fixed prosthesis, must extend at least two teeth an either side of the cleft to resist relapse tendencies.  Fixed prosthetic restorations are usually constructed at 20 years of age. By this time, no further adjustment in tooth position required and sufficient tooth structure can be removed in preparation for full crown coverage to provide necessary parallelism and gingival extension for retention and aesthetics.

Adults Prosthodontist will see patients who have not received optimum treatment and there are still who may require removable partial prosthesis to camoflage the

collapsed maxillary segments and reduced vertical development of maxilla.  Design of these prosthesis is further complicated when a pharyngeal obturator is incorporated to aid speech.  The edentulous cleft palate patient represents a failure in rehabilitation . The scarred palate, collapsed maxillary arch and resorbing alveolar ridges present severe handicaps to the patient as well as a challenge to the prosthodontist.

Retentin is probably more dependant on the skill and adaptability of the patient than on any other factor. Application of existing knowledge and currently available techniques of treatment can provide a more acceptable alternative.

PROSTHESIS USED IN CLEFT PALATE PATIENTS Prosthesis in infancy period • Feeding obturator • Premaxilla positioning applilances • Nasal conformer • Palatal lift prosthesis • Speech aid or speech bulb prosthesis • Obturators  Palatal obturator with solid and hollow bulbs.  Palato pharyngeal obturators with  Hinge  Horizontal  Meatus types • Prosthesis for adults  Removable prosthesis  Complete dentures  Fixed prosthesis  Implant supported prosthesis

Feeding Obturator Is a prosthetic aid that is designed to obdurate the cleft and restore the separation between oral and nasal cavities. It facilitates • Feeding • Reduces nasal regurgitation • Prevents tongue from entering the defect and allows Spontaneous growth of palatal shelves • Contribute to speech development • Reduces incidence of otitis media and other pharyngeal infections. Fabrication Preliminary impression tray is made with light polymersing acrylic resin (Triad VLC Reline material) . Adapt in baby’s mouth and light polymerize extra orally .

Preliminary impression is made with a thick mix of tissue conditioning

material (Coc soft, GC) • While the body is held with face towards the floor. • Custom tray is fabricated. Tried intra orally determine the easiest path of insertion. • Load the tray with Viscous Vinyl polysiloxane impression material. • Impression is made as mentioned above. Ensure proper nasal breathing and that baby is making sucking movements for border moulding . • Pour the cast, block the undercuts and acrylic resin prosthesis is fabricated.

• Review after 48 hours to detect pressure areas for ulceration .

After 3 months a new feeding obturator can be constructed to accommodate facial growth of the baby.

Pre-Maxilla positioning appliances In complete bilateral cleft cases, the premaxilla for prolabium are in protruded and rotated position. Premaxilla positioning appliance is a non- surgical technique that retracts and rotates the malposed segment to a more favourable position for lip repair. Fabrication   A hard resin palatal plate is made from a maxillary impression. An orthodontic button is attached to the polished surface on each side in the area overlying gum pads.

A 1.0cm2 by 2mm thick pad of soft denture reline material is added to a segment of an elastic orthodontic chain.

 

The ends of the chain is attached to the orthodontic buttons on the palate. The tissue side of the palatal plate is lined with resilient denture reline material for intimate contact.  The elastic chain is draped over the premaxillary segment with soft pad contacting the prolabium .  The palatal plate provides anchorage for the elastic chain as it delivers a low grade, steady, traction force of 5.0 grams in the premaxillary segment.  Adjustments are made periodically in the elastic chain for anterior portion of plate to allow continous retraction.

 A jack screw can be incorporated for expansion.

Nasal conformer Surgical repair of cleft lip can result in a flattened contour of the nasal alar cartilage.  Cosmetic deformity  Nasal airway obstruction A corrective surgical procedure needed Gregson et al (1999) described the case of a nasal orthopedic moulding appliance to minimize or avoid this problem. Fabrication A resin palatal plate is made for the infant at 2-3 weeks of age. A small projection of resin extends from the plate at the plate at the cleft lip site up toward the alar cartilage to slightly elevate it and mold it into proper contour. This conformer is retained with denture adhesive and is work continually except for daily cleaning until the cleft lip repair. Patient is recalled at an interval of 1-2 weeks during use.

PALATAL LIFT PROSTHESIS Velo pharyngeal in competency occurs when soft palate is of adequate length but inadequate mobility to achieve velopharyngeal closure. It covers the hard palate, extend posteriorly to engage the soft palate and physically elevate and extend it into proper position to achieve closure.

Most effective when the soft palate has little muscle tone and offers little resistance to elevation. Adequate retention must be achieved by clasping multiple teeth. Treatment usually starts at the age of 4.5 (± 1 year). It is used until the child is able to speak without any hypernasality of speech is reduced. The speech language therapist, together with the prosthodontist evaluate any recurring hypernasality.

Speech Aid or Speech Bulb Prosthesis A speech aid appliances is indicated, When speech develops for surgery cannot be performed due to systemic problems or if surgical dehiscence has occurred. Successful only if, Decidous – teeth have erupted , child is co-operative with placement of orthodontic bands and impressions. Earliest treatment should be done at the age of 2 ½ -3 year of age. Fabrication Orthodontic bands with a single edge wire buccal tube are placed on the second decidous molars. Irreversible hypercolloid impressions is made The prosthesis has 3 segments, • The palatal section with wrought wire clasps.

• The velar section • The pharyngeal or bulb section After the palatal section is finished a wire loop is added for the velar section, to act as a carrier for impression compound . The level of speech bulb at the level of the palatal shelf or atlas ot at level of passavant’s pad or ridge. The impression for speech bulb is formed by muscle movements during deglutition. Once acceptable closure is achieved, mouth temperature impression wax (IOWA Wax) is added for final adaption. This impression is then processed to fabricate the prosthesis in clear acrylic resin. Speech bulb can also be incorporated with orthodontic appliance with Jack Screw. OBTURATORS An obturator can be defined as a “Prosthesis used to close a congenital or acquired tissue opening, primarily of the hard palate and /or contiguous alveolar structures. Mainly 2 types: Palatal obturator  Palato pharyngeal obturators Palatal obturators Even after cleft palate surgery there may be a residual oronasal Communication in palate, alveolar ridge or labial vestibule and cause problems of speech and feeding.It may allow undesirable nasal air emission for compromised speech.

A palatal obturator Covers the opening and contribute to normal speech production. Eliminates hypernasality for assists speech therapy. It consists of mainly 2 portion 1. 2. Palatal porion Bulb portion

Bulb portion can be made soled or hollow Hollow bulb has reduced weight and increased retention and assists in resonance balance. Fabrication 1. Before impression  If the opening is small, it is closed with gauze dipped in petroleum jelly  If the opening is large, the impression material is added less in the area corresponding to the defect. 2. Preliminary impression is made using alginate if dentulous and using compound if edentulous. 3. Custom tray is fabricated, Border molding is done. Final impression is made with alginate or elastomeric impression material. The scar band area must be accurately reproduced. In dentulous, cast frame work with multiple clasping fabricated. In edentulous, obturator is processed along with complete dentures. Relining after necessary in edentulous cases.

PALATO PHARYNGEAL OBTURATORS Velo pharyngeal insufficiency occur when, The cleft palate is unrepaired or a surgically repaired soft palate is too short to make contact with pharyngeal walls during functions causing. • Excessive nasal airflow • Inadequate oral pressure for normal speech • Nasal regurgitation during feeding • Nasal regurgitation during feeding A palato pharyngeal obturator provides, velopharyngeal closure and contribute to normal functions. Mainly two parts; Palatal portion :- Covers hard palate velar portion - Seals the nasal Cavity from oropharejun during function 3 General Types 1. Hinge type 2. Fixed type 3. Meatus type Involves a mass of acrylic that is hinges to the base and supportedly move up and down , so the cleft soft palate moves. Not used because – Limited motion of cleft soft palate, that a velopharyngeal seal is not possible. Excess weight

Fixed type(Most commonly used)- Which is directed towards passavant’s pad. Meatus obturator :- It is directed almost 900 upward to reach the roof of nasophareynx Method of fabrication of meatus obturator  Definitive maxillary prosthesis is constructed initially  A wire loop is attached to the palatal terminus of the prosthesis.
 Modeling plastic is added sequentially to the wire loop to mold the obturator  As the obturator is formed, the clinician will be able to identify the

indentations formed by the inferior and middle conchae and the residual vomor.  After the obturator is formed it is reduced approximately 1mm with a scalpel for thermoplastic wax is added.  After processing the anterior –posterior dimension of the obturator is reduced to approximately 5 mm in thickness, to permit nasal Breathing and to reduce weight at this juncture , the patient will exhibit hypo nasality & nasal breathing will be difficult Sharry suggested placing a hole approximatively 5mm in diameter through the obturator to permit nasal breathing . Meatus obturator is indicated for patient with extensive defects of soft plate . They are obturator of choice for edentulous patients when retention is a problem . Removable Prosthesis : Removable prosthesis is preferred when there is a large anterior defect and /or the middle third of the face is depressed

Can be categorized into  Snap on type  Non-snap-on type Snap- on prosthesis In these type of prosthesis ,abutment teeth are prepared for full crowns and Dolder or other type of bar splinting is done. A gold framework is designed and cost to overlay the bicuspids and clasp the molars The clip .attachment engages the anterior cross arch bar. Occlusion us restored and middle face aesthics are achieved .A speech bulb can be incorporated in to the snap on prosthesis . Complete super imposed denture . Indicated in patients with adequate veloparyngeal closure and decreased vertical dimension of face, resulting from overclosure Full gold crowns are placed on all maxillary teeth Precision gold framework with claps for retention & stability for overlay denture fabricated . The overaly denture restores the vertical dimension of the face and gives an ideal arch form to the maxillary arch with full compliment of teeth. Non. Snap on prosthesis Patient with a full compliment of teeth may need. Only a frame work clasping the healthy abutment teeth. This framework carrier the palatal , velar and pharyngeal portions necessary for speech improvement .

Complete Dentures : It is difficult to plan a complete denture for a cleft plate patient because , the size of the maxilla will be very small. Interarch distance is usually increased and calss III relationship is common . Palatal vault – shallow, decreased residual ridge height , so stability is compromised Lack of boney palate , so the support in less. Scarring of the soft palate, so posterior palatal seal area is not recorded . Scar tissues rebound under the pressure . Hence relief should be provided . While impression making, small fistulous openings should be blocked out using a gauze dipped in petroleum jelly . Conventional border moudling is done. Impression made using light bodied rubber base impression material Permanent denture base fabricated. The maxillary occlusal rim should be controlled according to the scarred lip contour. Lower teeth are usually set first and consecutively used as a guide to set the maxillary anteriors . The tooth adjacent to the labial scar usually (lateral incisor) should be set above the occlusal plane with a slight rotation , to make the scar less conspicuous . The labial flange of the denture should be reduced for aesthetic reason s. An obturator bulb may be necessary to seal a posterior plate cleft. The bulbcan be fabricated over the denture a few weeks after denture insertion .

Fixed partial denture prosthesis These type of repair becomes the treatment of choice when the ridge defect is small. If bone graft was done to complete an alveolar cleft regular FPD can be fabricated . If bone graft were not done, then FPD is done with atleast 2 abutment on both sides of the cleft. Stabilization of mobile premaxilla can be clone by constructing an FPD from canine to canine.An anterior FPD & Prosthetic speech appliance framework can be given by interlocking on the lingual aspects. When there is no tooth loss, porcelain laminate veneers or crowns may be placed on an abnormally shaped lateral incisors . Implants : 1. Implants can be placed to replace single missing tooth eg: lateral incisor . 2. 3. Support an FPD implant can act as an abutment . In edentulous case, over denture can be made over the implants ie implants supported over dentures . Conclusion Prosthodontic treatment has a long and rich history in the care of patients with cleft lip& palate . Because of increased knowledge of craniofacial growth and development and improved surgical and orthodontic treatment , today’s cleft palate patients receive better care and in len time. This requires less prosthetic intervention . still prosthetics retains an important place in

cleft care and prosthodontist remains an integral member craniofacial rehabilitation team . References :


cleft –

1. Maxillofacial rehabilitation - prosthodontic & surgical considerations –

john Beumer , Thomas . A curtis & David.N.firtell
2. Maxillofacial prosthetics – multi disciplinary practice – Varoujan A chalian,

Joe.B. Draine, S.Miles. Stantish 3. Complete denture prosthodontics - John J.Sharry
4. Dental

& prosthodontic care for


with cleft

or craniofacial

conditions - David . J.Reisberg
5. The cleft plate – Vol.37 , No.6,P.534-537 . Facial clefts & cranio synostosis –

principles & management . Thimothy A.Tinvey . 6. Treatment of facial cleft deformities – An illustrated guide –kurt.W.Butou.

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