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.
Aetiology
-heredity
-infections
drugs{phenytoin,barbiturates etc} in first trimester of pregnancy
poor diet
hormonal imbalance
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.
9. 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 16 th century. Works by
snell, stearn, kingsley and sareson in 19th century describe current prosthetic
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 .
Infancy
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. Palatal porion
2. 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. Support an FPD implant can act as an abutment .
3. 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 of cleft –
craniofacial rehabilitation team .
References :
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 patients 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.