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0022-39 13 /82/090297 + 06$00.60,‘0 IN 1982 The C. V. Mosby Co THE JOURNAL OF PROSTHETIC DENTfSTRY 297
ABADI AND JOHNSON
PATHOGENESIS
In 1874, His described the embryologic forma ttion
of the central third of the face in a classic doctrine
which has persisted to modern times. Avery, in 1947,
based on this, explained the cleft lip as failure of
fusion of the medium nasal and maxillary processes.
In 1961, Vaiauri’O stated that the cleft lip was
located at the line where, during the second month
of development, the maxillary process should have
fused with the nasiomedial process. At present, two
new concepts have been raised for further investiga-
tion. The first hypothesis is the preexistence of clefts
of the lip; the other view suggests that clefts result
from “accented development.”
Shafer et al.” state that the cleft palate appears to
represent a disturbance in the normal fusion of the
Fig. 3. All undercuts, including free gingival margins,
palatal shelves, which is a “failure to unite due to
are blocked out. Vertical dimension of occlusion is
opened to allow space for denture teeth. lack of force, interference by the tongue, or a
disparity in the size of the parts involved.” They
identify other factors to be considered in the etiology
occurs in about 1 in 1,000; cleft palate occurs in 1 in of cleft palate such as; (1) a defective vascular supply
2,500 live births in the white population. American to the involved region, (2) a mechanical disturbance
blacks demonstrate a lower frequency for incidence in which the size of the tongue may prevent the
of cleft palate, while the Japanese population expe- union of parts, (3) circulating substances such as
riences a higher rate in cleft palates. Sex differences alcohol and certain drugs and toxins, (4) infections,
in cleft palates are inconsistent, although the cleft lip and (5) lack of inherent developmental force.”
is present more often in males and the cleft palate is Bhatia’* refers to a single mutant gene producing
more common in females.s one large defect or a number of genes each producing
Fig. 5. Denture teeth are ground on lingual surface to Fig. 7. Processed denture prior to final insertion.
allow space to overlay natural teeth.
Fig. 9. A and B, Cleft palate patient before treatment. C, Cleft palate patient after prosthetic
treatment.
patients, since it improves the esthetic appearance, As an initial step in construction of the overden-
oral function, and soft tissue support for the ture, stock trays and an irreversible hydrocolloid
patient.‘j It also helps preserve existing tissue and material are used to make impressions of the maxil-
structures. lary and mandibular arches. Casts are then poured
The following procedure has been utilized in both in mircrostone and surveyed to define the best path
adults and children with a high degree of success. of placement. All undesirable undercuts are waxed
out, with blockout wax placed around the free
CLINICAL AND LABORATORY PROCEDURES margin of the gingiva on each tooth (Fig. 3). The
Full mouth radiographs, diagnostic casts, and a master casts are duplicated with a reversible hydro-
complete health history are obtained to provide a colloid impression material, and casts are poured in
treatment plan. Supportive procedures such as resto- microstone.
ration of carious teeth, extractions, and periodontal The maxillary cast is coated with a separating
treatment should be performed. Sharp cusps should medium such as sodium alginate. A base of autopol-
be trimmed from the teeth using conservative odon- ymerizing resin, constructed using the “sprinkle-on
toplastic procedures. Oral hygiene instructions must technique, ” should cover half of the occlusal surfaces
be reinforced as an important concept of the treat- of the teeth to allow adequate space for the denture
ment sequence, since the final outcome will depend teeth (Fig. 4).
on the patient’s ability to achieve effective plaque A face-bow transfer is made, and the maxillary
control. cast is mounted on the articulator of choice. Vertical
Fig. 10. Cleft palate patient. A, before and, B, after prosthetic treatment
dimension of occlusion is established by phonetic manner.‘” The dentures are inserted in the patient’s
criteria and sibilant sounds.1G Preliminary jaw rela- mouth and pressure indicating paste and disclosing
tions are obtained, and the mandibular cast is wax are used for the reduction of impinging areas
mounted on the articulator. The vertical dimension and necessary occlusal adjustments.
of occlusion of most cleft palate patients is slightly Since a border-molded impression was not made
closed; to compensate for this discrepancy, the cen- initially, a functional impression is necessary at this
tric relation record is made at a slightly greater time. The tissue surface of the denture and the
vertical dimension than the patient’s present vertical denture borders are relieved approximately 1 mm to
dimension of occlusion (Fig. 3). This increases the allow for impression material. Stops may be placed if
space available for arrangement of the denture so desired.
teeth. Tissue conditioning material is mixed and placed
The interocclusal distance is checked at the trial on the tissue surface of the denture base. The denture
denture appointment. Acrylic resin teeth of the is placed in the mouth, and the patient is allowed to
proper shade and mold are selected and ground on close lightly with the teeth in centric occlusion. Care
the lingual aspect to allow space to overlay the must be taken not to displace the denture in an
existing teeth (Fig. 5). Posterior teeth are also anterior direction. Border molding can now be
reduced to fit into the available space. The artificial accomplished both manually and functionally. After
teeth are arranged, and the denture is waxed so that approximately 5 minutes, the denture is removed
it will be esthetically pleasing (Fig. 6). After the from the mouth to evaluate the impression. It should
denture is tried in the patient’s mouth to verify jaw be smooth and free of imperfections and should
relations, check esthetics, and make eccentric demonstrate an accurate reproduction of the
records, it is returned to the articulator to complete patient’s tissue.
the final arrangement of the artificial teeth for bal- The patient is requested to wear the denture for 2
anced occlusion and to complete the final waxing. to 3 days, after which the impression is reevaluated.
The denture is processed in the conventional If the functional impression is acceptable. the den-
ture is reprocessed, finished, and ready for final the psychologic and social acceptance of the cleft
insertion (Fig. 7). Again pressure-indicating paste palate patient.
and disclosing wax are used to reveal areas of REFERENCES
pressure on the tissue. After all adjustments are
1. Rahn, A. O., and Boucher, L. J.: Maxillofacial Prosthetics:
performed, the patient is released (Fig. 8). Adjust- Principles and Concepts. Philadelphia, 1970, W. B. Saunders
ments are scheduled at 24- and 48-hour and l-week co.
intervals, after which the patient is placed on a 2. Cooper, H.: Psychological, orthodontic and prosthetic
3-month recall. approaches in rehabilitation of the cleft palate patient. Dent
Clin North Am, July 1960, pp 381-393.
DISCUSSION 3. Archer, N. H.: Oral Maxillofacial Surgery, volume 2, ed 5.
Philadelphia, 1975, W. B. Saunders Co.
The procedure outlined for prosthodontically 4. Chierici, G.: Some observations on the pharyngeal airspace.
treating the adult and child cleft palate patient Cleft Palate J 4:129, 1967.
results in accurately fitting and comfortable pros- 5. Harkins, C. S.: Principles of Cleft Palate Prosthesis: Aspects
in the Rehabilitation of the Cleft Palate Individual. Pub-
theses. A similar procedure which has been outlined
lished for Temple University Publications, Philadelphia,
by Brewer” has shown excellent results. New York, 1960, Columbia University Press.
The necessity for good oral hygiene for the cleft 6. Adisman, I. K.: Cleft palate prosthetics. In Grabb, W. C.,
palate patient must be stressed. In addition to good Rosenstein, S. W., and Bzock, K. R., editors: Cleft Lip and
brushing and flossing techniques, the patient should Palate: Surgical, Dental and Speech Aspects. Boston, 197 1,
Little, Brown, and Co.
use 4% stannous flouride on the denture daily to
7. Gorlin, R. J., Pindborg, J. J., and Cohen, M. M.: Syndromes
minimize the chance of dental caries. If the vertical of the Head and Neck, ed 2. New York, 1976, McGraw-Hill
dimension of occlusion is too great and there is not Book Co.
sufficient interocclusal distance, the possibility exists 8. Tiek, R. W.: Oral Pathology. New York, 1965, McGraw-Hill
that the patient’s chewing may cause the natural Book Co.
9. Fraser, F. C.: The genetics of cleft lip and palate. Am J Hum
teeth to abrade through the base. If multiple natural
Genet 22:336, 1970.
teeth are involved in the procedure, care must be 10. Valauri, A. J.: Cleft palate prosthetics. In Converse, J. M.:
taken to assure a good fit to prevent breakage of the Reconstruction Plastic Surgery, vol 4. New York, 1977, W.
denture. In addition, a child treated with this cleft B. Saunders Co.
palate technique will require a new prosthesis con- 11. Shafer, W. G., et al.: A Textbook of Oral Pathology, ed 3.
Philadelphia, 1974, W. B. Saunders Co.
structed every 1% to 2 years to allow for skeletal
12. Bhatia, S. N.: Genetics of cleft lip and palate. Br Dent J
growth. 132:95, 1972.
13. Strean, L.P., and Peer, L.A.: Stress as an etiologic factor. in
SUMMARY the development of cleft palate. Plast Reconstr Surg 18: 1,
The role of the prosthodontist in the multidiscipli- 1956.
14. Beder, 0. E., Coe, H. E., Braafladt, R. P., and Houle, J. D.:
nary approach to the treatment of the cleft palate
Factors associated with congenital cleft lip and cleft plate in
patient has been described. A brief review of the the Pacific northwest. Oral Surg 9:1267, 1956.
literature on the historical background, epidemiolo- 15. Brewer, A. A., and Fenton, A. H.: The over denture. Dent
gy, and pathogenesis of the cleft palatal defect has Clin North Am 723-746, 1973.
been presented. A technique for constructing a cleft 16. Ellinger, C. W., Rayson, J. H., Terry, J. M., and Rahn,
A. 0.: Synopsis of Complete Dentures. Philadelphia, 1975,
palate prosthesis has been outlined in detail. Treat-
Lea and Febiger, Publishers.
ment of several patients using this technique has
Rcfni;nt requeststo:
produced excellent results.
DR. BEHRUZJ. ABADI
Prosthetic therapy aids the patient in developing UNIVERSITY OF KENTUCKY
normal speech, promoting deglutition and mastica- COLLEGE OF DENTISTRY
tion and in closing off the oral cavity from the nasal LEXINGTON.KY 40536
cavity. The esthetic benefits can be instrumental in