Maxillary Rehabilitation Using a Removable Partial

Denture with Attachments in a Cleft Lip and Palate Patient:

A Clinical Report
Marina Rechden Lobato Palmeiro, DDS, MS, PhD, Caroline Scheeren Piffer, DDS, MS,
Vivian Martins Brunetto, DDS, Paulo César Maccari, DDS, MS, PhD, &
Rosemary Sadami Arai Shinkai, DDS, MS, PhD
Department of Prosthodontics, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Keywords
Telescopic crowns; dental prosthesis; birth
defects; quality of life; cleft lip; cleft palate;
removable partial denture; removable
prosthesis; telescopic retainers.
Correspondence
Marina Rechden Lobato Palmeiro, Pontifical
Catholic University of Rio Grande do Sul –
School of Dentistry, Av. Ipiranga, 6681 Prédio
6, Porto Alegre, RS 90619-900, Brazil.
E-mail: marina.lobato@pucrs.br
Abstract
Clefts of the lip and/or palate (CLP) are oral-facial defects that affect health and
overall quality of life. CLP patients often need multidisciplinary treatment to restore
oral function and esthetics. This paper describes the oral rehabilitation of a CLP adult
patient who had maxillary bone and tooth loss, resulting in decreased occlusal vertical
dimension. Functional and cosmetic rehabilitation was achieved using a maxillary
removable partial denture (RPD) attached to telescopic crowns. Attachment-retained
RPDs may be a cost-effective alternative for oral rehabilitation in challenging cases
with substantial loss of oral tissues, especially when treatment with fixed dental
prostheses and/or dental implants is not possible.

This research was partially supported by the

Brazilian Ministry of Education and Culture/
CAPES (BEX: 12312-12-6 and CAPES I
scholarship for M.R.L. Palmeiro).

The authors deny any conflicts of interest.

Accepted January 22, 2014

doi: 10.1111/jopr.12188

Clefts of the lip and/or palate (CLP) are oral-facial defects that
affect the health, quality of life, and socioeconomic well-being
of both the affected individuals and their families.1-3 Clefts are
associated with cosmetic deformities and dental abnormalities;
difficulties with speaking, chewing, and swallowing; and psy-
chological problems.4-6 Treatment of CLP patients spans from
birth to adulthood and often requires a multidisciplinary team of
nurses, plastic surgeons, oral and maxillofacial surgeons, oto-
laryngologists, speech therapists, psychologists, orthodontists,
and prosthodontists.7-10
In the older generation of CLP patients (those born in the 20th
century) there are some problems with residual fistulae (scar-
ring), and surgery and orthodontics cannot achieve a complete
oral rehabilitation without a complementary prosthodontic ap-
proach. Restorative dentistry offers several options for pros-
thetic rehabilitation in patients with clefts. These options in-
clude fixed partial dentures (FPDs), removable partial dentures
(RPDs), adhesive FPDs, and implant-supported dentures.2,11-13
Because many types of surgery performed in cleft patients
result in anatomical and functional complications, some mod-
ifications from conventional prosthetic treatment may be nec-
essary to achieve satisfactory functional and esthetic results.
This study presents a case involving the oral rehabilitation of
one adult CLP patient using an RPD connected with telescopic
crowns.
Clinical report
A 54-year-old woman with a unilateral cleft lip and hard palate
on the left side was referred to the Prosthodontics Clinic Unit
of the PUCRS School of Dentistry. She stated that she avoided
social contact because of her physical appearance. Another
complaint was difficulty in chewing due to missing and in-
correctly positioned teeth, as well as temporomandibular joint
discomfort. An initial X-ray, before the treatment, revealed the
absence of bone in the cleft region, periapical lesion on tooth

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Oral Rehabilitation in a Cleft Lip and Palate Patient
Figure 1 Initial appearance before prosthetic treatment. (A) Panoramic
X-ray: area with bone defect between teeth 21 and 22. (B) Front view,
missing teeth in the maxillary arch, and misaligned teeth 23–25. (C)
Occlusal view, surgical scar from surgery procedures for correction of
the oral-facial defect.
11, periodontal lesion on teeth 14 and 27, impaction of tooth 18,
and misalignment of tooth 23 (Fig 1A). Nonsurgical periodon-
tal therapy, root canal treatment of tooth 11, and extraction
of teeth 14 and 27 were performed. After the initial therapy,
clinical reevaluation showed teeth 14–17, 21, 22, and 27 were
missing, and tooth 23 was misaligned (Fig 1B). Abnormal tooth
color was associated with external factors (staining from intake
of dark colored foods and smoking). Furthermore, a scar from
correction of the left unilateral CLP was observed (Fig 1C).
2 Journal of Prosthodontics 00 (2014) 1–4 
Palmeiro et al
Figure 2 Tooth preparations for fabrication of telescopic crowns. (A)
Occlusal view. (B) Inner telescopic copings, supragingival location of the
crown edge.
Diagnostic models were mounted on a semi-adjustable artic-
ulator to plan treatment. The patient was missing bone tissue
in the maxilla, but bone grafts and dental implants were not a
primary option because she was an active heavy smoker and
asked for a nonsurgical treatment. The absence of teeth 14–17,
resulting in a large prosthetic space (free end), excluded the
possibility of an FPD in the right hemi-arch. A conventional
RPD would neither seal the oronasal communication nor sup-
port the upper lip. Thus, the chosen treatment plan consisted
of an association of RPD, attachments, and telescopic crowns
to seal the oronasal communication and restore function and
esthetics.
Extraction of tooth 23 was indicated and performed to fa-
cilitate the path of insertion of the RPD. Teeth 11–13, 24, and
25 were prepared for telescopic crown fabrication (Fig 2A).
According to the Glossary of Prosthodontic Terms, a telescopic
crown is “an artificial crown constructed to fit over a coping
(framework). The coping can be another crown, a bar, or any
suitable rigid support for the dental prosthesis.”14 Some authors
describe the telescopic retainer as an inner telescopic coping,
or sleeve coping, cemented to the dental abutment that tele-
scopes within an outer telescopic coping, or secondary crown,
connected to a detachable prosthesis.9,15-17
After tooth preparation, a full-arch impression was obtained
with an acrylic custom tray and addition silicone (ExpressTM ;
3M ESPE, Seefeld, Germany). The casts were mounted on the
C 2014 by the American College of Prosthodontists
Palmeiro et al
Figure 3 Internal view of the removable partial prosthesis with the ma-
trix connectors on the telescopic crowns. An extracoronal retaining ele-
ment (SD-attachment; Servo-Dental GmbH & Co. KG, Hagen, Germany)
was added to copings of teeth 24 and 13 to improve retention.
semi-adjustable articulator in centric relation for the fabrica-
tion of the inner telescopic copings. On teeth 13 and 24, an ex-
tracoronal retaining attachment (SD attachment; Servo-dental,
Hagen, Germany) was added for extra retention. Telescopic
crowns were custom made with patrix connectors to support
the RPD with matrix connectors and to splint the remaining
teeth. The metal copings cast in nickel-chromium alloy (Dan
Ceramalloy, Osaka, Japan) were tried in, and fit accuracy was
verified (Fig 2B).
A second full-arch impression with silicone was made to
transfer the position of the inner telescopic copings in relation
to the maxilla. A new cast was remounted for laboratory fab-
rication of the outer telescopic copings and RPD framework.
Both metal structures were tested clinically to check fit and oc-
clusion. A bite record was made using a wax baseplate attached
to the RPD saddle. Facial parameters such as lip support, smile
line, and upper lip length were evaluated, and vertical dimen-
sion was reestablished before selection of artificial tooth size
and color. After a wax-up trial with the patient’s approval, the
RPD was finished in the laboratory (Fig 3).
In the following clinical session, the crowns and RPD were
adjusted and installed. The inner telescopic copings were ce-
mented with resin-modified glass ionomer cement (RelyX Lut-
ing Plus; 3M ESPE, St. Paul, MN). The RPD was immedi-
ately positioned over the dental abutments, providing a splint
to form a stabilized polygon (Fig 4). The patient was in-
structed on how to wear the RPD. Oral hygiene instructions
were also given, such as removing the prosthesis for cleaning
after meals and brushing teeth at least three times a day. Re-
calls were completed weekly for 1 month, then every 6 months.
The procedures described in this report were successful, and
the results surpassed the patient’s cosmetic and functional
needs.
Discussion
Oral rehabilitation in CLP patients requires an interdisciplinary
view to make the prosthesis capable of blocking oronasal com-
munication, restoring masticatory and phonetic functions, and
Journal of Prosthodontics 00 (2014) 1–4 
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Oral Rehabilitation in a Cleft Lip and Palate Patient
Figure 4 Final appearance after prosthetic treatment. (A) Front extraoral
view. (B) Intraoral view.
improving cosmetics considering the overall cost/benefit anal-
ysis and gain in quality of life.8,9,12,13 Choosing between the
many prosthetic rehabilitation options is based on the specific
clinical situation of the patient and his/her main complaints
and wishes. Clinical examination should evaluate not only the
dental conditions but also the presence and extension of alve-
olar ridge defects, scar tissue, and oronasal communication.7-9
It is the responsibility of the prosthodontist to provide a
prosthesis that should be simple to handle and easy to
maintain.
The treatment plan presented here consisted of a maxillary
rehabilitation using an association of RPD, attachments, and
telescopic crowns to seal the oronasal communication and re-
store dental occlusion and lip support.9,15 The patient chose
this treatment option because the procedures were less com-
plex, less invasive, less expensive, and less time consuming
than alternatives involving bone grafts and dental implants. A
systematic review demonstrated that complications occur early
in most cases of implant-supported prostheses in patients with
clefts.12 The fact that the patient can remove the prosthesis also
facilitates the hygiene of dental abutments and residual cleft
under the RPD.
If the implant placement conditions are not ideal, and ad-
jacent teeth need cosmetic corrections, conventional pros-
theses may be the best treatment option; however, adhe-
sive fixed prostheses with minimally invasive preparations are
not indicated for definitive treatment of patients with clefts
3
Oral Rehabilitation in a Cleft Lip and Palate Patient
because small premaxillary movements or mobility of the
dental abutments can cause cement failure.11 Another com-
mon problem in CLP patients is deficient lip support. Re-
movable prostheses are indicated in cases with severe bone
loss that affects the lip position or when the cleft needs to
be blocked.9,13 The major resistance to using RPDs for par-
tially edentulous patients is due to cosmetic reasons, such as
the visibility of metallic clamps, as well as functional con-
cerns during speech and chewing because the prostheses are not
fixed.11
The principles involved in the use of telescopic crowns
and RPDs have been well described in the literature as a
valuable therapy option.15-17 Yalisove and Dietz16 reported
the following advantages of this treatment modality: acces-
sibility to oral hygiene maintenance by the patient; reduc-
tion of lateral stress on abutment teeth; independence of the
individual abutments; use of weak abutments with question-
able prognosis that should not be used in an FPD; bilateral
splinting; and esthetic replacement of extensive alveolar bone
loss.15,16
In this clinical case, the prosthetic rehabilitation using an
RPD connected to telescopic crowns successfully splinted and
corrected the position of the remaining teeth. When connected
to the RPD, telescopic crowns increase the prosthetic stability
and retention, optimize favorable force transmission to the long
dental axis, and improve esthetics.9,14 The present findings us-
ing telescopic crowns are in line with Yalisove’s15,16 reports,
which suggested that, apart from the benefits mentioned above,
other benefits include maintenance of centric relation and oc-
clusal vertical dimension, preservation of the ridges, minimal
number of adjustments, and improvement in patient acceptance,
from the standpoint of function and psychological impact.15,16
A positive impact on daily living and quality of life has been
reported following restoration with an RPD retained by tele-
scopic crowns, particularly for patients with few remaining
teeth.17,18
Conclusion
There are several treatment options for patients with CLP; how-
ever, in patients missing several dental elements (making den-
tal treatment difficult) and/or those who have experienced bone
loss, a good option may be removable partial prostheses con-
nected to telescopic crowns. This report shows that this alter-
native is effective for patients missing various dental elements
and who lack osseous tissue and lip support as it corrects den-
tal misalignment, restoring oral function, esthetics, and overall
satisfaction.
Acknowledgments
The authors thank the patient who participated in this study, as
well as all the staff at PUCRS School of Dentistry.
4 Journal of Prosthodontics 00 (2014) 1–4 
Palmeiro et al
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C 2014 by the American College of Prosthodontists