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MAXILLOFACIAL PROSTHETICS l DENTAL IMPLANTS

SECTION EDITORS
I. KENNETH ADISMAN RONALD I’. DESJARDINS

The prodtdontic management of cleft palate


Behruz J. Abadi, D.M.D.,* and Jeffrey David Johnson, D.M.D.**
University of Kentucky, College of Dentistry, Lexington, Ky.

T reatment of cleft palates and cleft lips provides a


tremendous challenge-to the prosthodon&. For cleft
palate patients, prosthetic restoration aids in devel-
oping normal speech, promotes deglutition and mas-
tication, and separates the oral cavity from the nasal
cavity.’ In addition, the esthetic benefits of the
obturator can be instrumental in the total rehabili-
tation of these handicapped individuals.’
Surgical treatment for the cleft lip is usually
scheduled 1 to 2 weeks after birth, while surgical
correction of the cleft palate depends upon the type
of deformity and occurs between 1 and 6 years of
age. Cleft palate repair (palatorrhaphy) provides
many of the same advantages as prosthetic treat-
ment. In addition, cleft palate surgery can minimize
the chances for development of middle ear disease
and consequent hearing loss, ensure normal growth
Fig. 1. Cleft palate patient prior to prosthetic treat-
patterns of the bones of the midface, and provide an ment.
environment for normal development and eruption
of the teeth.!
The prosthodontist should be included in the speech. He designed five different types of prostheses
planning and treatment team for cleft palate using this principle. In 1929, Fitzgibons designed a
patients from the time the team is formed. Until fixed obturator made of gold. The principles which
surgical correction of the cleft palate is accom- he used are still evident today, although different
plished, the use of an obturator to aid in feeding and materials are used. Most modern cleft palate pros-
to maintain an adequate airway can be of value to theses are of the rigid type, composed of an acrylic
the infant.’ In the later stages of treatment, the role resin obturator or pharyngeal extension attached to
of the prosthodontist becomes most important in the a metal framework.”
multidisciplinary approach.
EPIDEMIOLOGY
HISTORICAL PERSPECTIVE Estimates of prenatal and neonatal death of indi-
In 1511, Amatus Lusitonius constructed the first viduals with cleft disorders vary between 17% and
known prosthesis designed to improve the speech of 25%, with a significant number of fetuses dying
the cleft palate patient. Other prosthodontists who before facial clefts can be detected.‘,
have contributed to the process of cleft palate In terms of the total number of facial clefts, the
treatment include Ambroise Pare, who, in 1531, incidence for cleft lip ranges between 20%, and 30%.
outlined the basic treatment principles for cleft Cleft lip, with or without cleft palate, occurs 35%, to
patients. In 1881 Pierre Fauchard advocated nasal 50% of the time, with isolated cleft palate evident in
and pharyngeal extensions to a denture base to aid in 30% to 45% of cleft palates.’ All clefts of the lip and
palate range in different populations from approxi-
*Assistant Professor, Department of Prosthodontics. mately 0.59 in 1,000 to 3.63 in 1,000 live births.’
*‘Postdoctoral student. Department of Periodontics. In general, cleft lip with our without cleft palate

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

Fig. 4. Denture base covers only half of occlusal surface


to allow more space for denture teeth.
Fig. 2. After surgical repair, cleft remains open necessi-
tating prosthetic treatment.
Several investigators have shown that approxi-
mately 85% of cleft lip cases are unilateral. Of these,
more than two-thirds occur on the left side regardless

I of sex or extent of the cleft.

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

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CLEFT PALATE PATIENTS

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. 6. Final arrangement and waxing of prosthesis.

a small defect as the cause for the cleft lip or


palate.
Strean and Peer’” explained that stress of physio- Fig. 8. Patient after receiving over-denture.
logic, emotional, or traumatic origin may be an
important factor in the etiology of cleft palate. They
conducted a study of 228 mothers of cleft palate systems, cardiovascular and digestive systems, and
children based on the premise that stress induces an other miscellaneous anomalies such as double mons-
increased function of the adrenal cortex and ter, albinism, and nail dystrophy were involved in
increased hydrocortisone secretion. these various abnormalities.
Clinically, cleft palate has been shown to be The patient with a cleft palate deformity poses a
associated with other developmental abnormalities unique challenge to the prosthodontist (,Figs. 1 and
in about 50% of patients. Beder et al.” found that the 2). The overdenture technique is not a new concept,
central and peripheral nervous systems, the osseous and in recent years it has become accepted as the
and muscular systems, sense organs, genitourinary preferred method of treatment for many cleft palate

THE JOURNAL OF PROSTHETIC DENTISTRY 299


ABADI AND JOHNSON

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

300 SEPTEMBER 1982 VOLUME 48 NUMBER 3


CLEFI’ PALATE PATIENTS

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-

THE JOURNAL OF PROSTHETIC DENTISTRY 301


ABADI AND JOHNSON

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
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Clin North Am, July 1960, pp 381-393.
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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
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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.,
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9. Fraser, F. C.: The genetics of cleft lip and palate. Am J Hum
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teeth are involved in the procedure, care must be 10. Valauri, A. J.: Cleft palate prosthetics. In Converse, J. M.:
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SUMMARY the development of cleft palate. Plast Reconstr Surg 18: 1,
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14. Beder, 0. E., Coe, H. E., Braafladt, R. P., and Houle, J. D.:
nary approach to the treatment of the cleft palate
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patient has been described. A brief review of the the Pacific northwest. Oral Surg 9:1267, 1956.
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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

302 SEPTEMBER1982 VOLUME 48 NUMBER 3

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