PROSTHETIC REHABILITATION

FOR ORAL CLEFT PATIENTS

- R. Madhuvathani
CRI ( I2 BATCH )
DEPARTMENT OF PROSTHODONTICS
 CONTENTS
• Introduction
• Etiology
• Classification
• Psychological crisis in cleft patients
• Multidisciplinary approach
• Definitive prosthodontic treatment
• Conclusion
 INTRODUCTION

• Cleft lip and cleft palate are congenital abnormalities

resulting from incomplete development of the lip and / or
palate in early few weeks of pregnancy.
• This can be associated with syndromes or non -
syndromic.
 ETIOLOGY
• The development of lip and palate occurs between 5 - 12 weeks of
gestation.
• Thus any disturbances during this period may lead to cleft lip and palate.

 Infections and toxicity  Genetic factors

 Poor diet and vitamin  Consumption of alcohol
deficiency  Certain drug consumption
 Hormonal imbalance
CLASSIFICATION
PSYCHOLOGICAL CRISIS IN CLEFT
PATIENTS
• Cleft patients with face disfigurement and loss of important biological
functions such as speech or swallowing, will experience changes in social
acceptance.
• In the process of recording the history of affected individuals or their
parents, we can assess their mental status.
• It is important to know the underlying emotional stresses and expectations
of the patient about the Prosthetic rehabilitation.
• We need to explain the treatment plan and achievable results in order to
prepare the patient before we start the treatment.
MULTIDISCIPLINARY APPROACH
• Treatment of the clefts varies according to their severity.
• Begins at birth and is usually not completed until the end of 2nd
decade.
• Multidisciplinary management, with interaction among the
various specialists of the cleft palate team is essential in order to
achieve optimum results.
• Feeding problems are addressed to ensure proper
nutrition of the child.
• Lip Surgery is performed at 3 months of age ( rule of
10 )
• Palatal surgery ( 12 months - 4 years of age )
• Role of orthodontist - expansion of maxillary arch and
alignment.
• Placement of bone grafts in Alveolar cleft.
• Definitive prosthodontic treatment is indicated during
adolescent growth and development when tooth
maturation is essentially completed.
 Cleft lip closure

Cleft palate closure

 Maxillary expansion

Alveolar cleft closure

with bone graft
 DEFINITIVE PROSTHODONTIC
TREATMENT
• In Early Adolescence.
• Initially - fabrication of a well - fitting interim removable
partial denture to replace missing teeth is fabricated.
• Partial denture may also work as lingual retainer to prevent
relapse after the orthodontic treatment.
 Interim removable partial denture

As lingual retainer
 FIXED PROSTHESIS
• Indicated in presence of
- Malformed tooth ( size, shape , hypoplastic enamel )
- Discolored dentition
- Presence of healthy abutment to support the prosthesis
- Minimal number of missing teeth
• Good oral hygiene has to be maintained by the patients.
Edentulous Discoloured tooth Malformed tooth
• Implants can be placed if the bone graft placed in the alveolar
defect has matured.
• Maryland bridges or porcelain fused metal crown units can be used
to replace the edentulous areas.
• For discoloured tooth, composite resin / porcelain veneers can be
used.
REMOVABLE PARTIAL DENTURES
• For patients with repaired cleft lip and palate RPDs have similar
design and functional requirements as the partial dentures for non
- cleft patients.
• When the cleft is not repaired or if the defect persist even after
sugical attempts, then the conventional prosthesis must support
the defect and act as an obturator too.
Considerations during impression making :

 If the defect is small, the irreversible hydrocolloid

material can get stuck or get aspirated .
 Thus the defect has to be blocked out with a gauze strip
lubricated with petroleum jelly prior to impression
making.
 If the defect is larger, it can be utilised to enhance the
retention with extension into the defect with acrylic
resin or soft silicone materials.
 COMPLETE DENTURES
Challenges :
• Decreased size of cleft maxilla
• Excessive interarch space
• Lack of bony palate
• Poor Alveolar ridge development & shallow depth of palate
• Scarring from lip closure
 IMPRESSION :

• Customary denture impression technique can be used with few

exceptions.
• Block out of small bony defects
• Zinc oxide eugenol and plaster wash impression should not be used.

Primary impression Custom tray

( Alginate ) Border moulding
fabrication

Secondary impression ( rubber based materials)

During border moulding :

• Avoid over extension in maxillary labial flange ( in

relation to the scar bands resulting from lip closure )
• Lip movements - downward, forward and lateral
movement
• Posterior palatal seal - should not be established across
the scar rather have to follow the creases and folds of scar
tissue.
• Scar tissues has the ability to rebound if displaced leading
to reduced retention.
 VERTICAL DIMENSION OF OCCLUSION :

• Generally, appropriate occlusal platform for the mandibular

teeth and arch is located followed by varying the vertical
position of maxillary arch based on level of retention,
stability and support available.
• Face bow record is made and the casts are mounted on the
articulator.
• Centric relation is recorded.
 TRY IN :

• Lip tends to frame the anterior teeth arrangement.

• Teeth are arranged and verification of esthetics and centric
relation are done during the try in appointment.
• If obturator has to be present, a wire loop for retention of
obturator segment is attached with wax and checked for
position at the 2nd try in appointment.
• Denture is flasked and dewaxing, packing and curing are
done and denture is thus fabricated and delivered.
 MAXILLARY OVER DENTURES
• Supported either by remaining teeth, a combination of
remaining teeth and implant or implants alone.
OSSEOINTEGRATED IMPLANTS
Advantages:
Abutment teeth preparation not required
Decreased possibility of damage to dental pulp
Excessive loading of abutment is avoided.
 CONCLUSION
• Proper planning coupled with early intervention will result in
Esthetic and functional restoration for patients with cleft palate.
• It seems that changes related to aesthetics, function and
psychological well-being after achievable Prosthetic rehabilitation
has an impact on patients personal lives and also provides great
satisfaction for the care - givers.