prosthetic management of cleft lip and palate patient
TRANSCRIPT
Prosthetic management of cleft lip and palate
Presented by Sanjiv Bairwa
PG 1st yr Prosthodontics Dept.Jaipur dental college
Introduction Classification Impression material Impression position Impression trays Feeding plate Tooth replacement Conclusion References
Contents
The oral rehabilitation of individuals with cleft lip and palate is directly related to severity of anatomical and functional alterations determined by malformation and the age at treatment.
The ideal treatment of cleft area is closure by bone graft and orthodontics, when this not feasible, many cases are solved with prosthetic rehabilitations.
Introduction
According to mazaheri, 60% of individuals with clefts will require some type of denture, and this percentage tends to increase if cleft affects the alveolar ridge.
The prosthetic rehabilitation contributes directly and positively to the psychological aspects of individual.
The main prosthetic treatment involved in oral rehabilitation of the individuals with cleft lip and palate are --
Fixed partial denture Removable partial denture Complete denture Implant-supported denture.
Anatomy
Orbicularis oris
Cupids Bow Philtral column Dimple
Vermilion border
Tubercle
Any opening or division inSome part of anatomy thatIs not normally open or Divided.
What is cleft ?
What is Cleft lip or Palate
Cleft lip
Class 1: incomplete cleft involving only the soft palate
Class 2 :cleft involving the hard and soft palate
Class 3 :complete unilateral cleft involving the lip and palate
Class 4 :complete bilateral cleft
Veaus classification
Teamwork
Surgery
Dentistry - Pedodontist Orthodontist Prosthodontist Maxillofacial surgery
Speech therapist
Audiology
ENT
Pediatrics
Psychology
• Elastomeric impression material.
Polyvinyal siloxane
• Irreversible hydrocolloids
Alginate • Low fusing and
medium fusing impression compounds.
Green stick
Impression materials
Impression compound
It is a thermoplastic impression material and used for impressions of infant with oral clefts.
Impression compound
•Easy removal
•Better resistance
Advantages
• Scalding or burnDisadvantages
Green stick compound is a low fusing impression compound.
Advantage Softened easily and quite Hard on setting
Disadvantage Can cause burn
Low fusing impression compound
AlginateAdavnatge Ease of mixing and manipulation Economical Pleasant color and taste
Disadvantage Poor tear strength
Irreversible hydroclloids
Use of Fast setting color timed alginate has been suggested in cleft infants , which has advantages to record the details even in presence of saliva.
Advantage Comfortable to patient Easy to manipulate Relatively inexpensive Prevents respiratory arrest
Elastomeric impression materialElastomeric impression materialsare better suited in making of cleftimpression and they don’t lead toany complications.
Advantage good elastic behaviour high tear strength accurate reproduction of surface detail long term dimensional stability
In Infants The most important part of the oral rehabilitation of
a patient with cleft lip and cleft palate is the impression making procedure.
The making of the impression in an infant with a cleft palate is a critical procedure.
For an accurate and safe impression procedure, a proper patient and dentist position are vital.
Impression position
A no. of impression positions have been adopted for cleft palate in infants are --
Positions
Facedown
Upright
Prone
Upside down
Facedown position
Upright position
Selection of Impression trays
• Use of wax• Icecream stick
• Hand adaptation
• Reverse side of spoon
Use of wax
Prefabricated trays that are commercially available(coe laboratory, chicago)for cleft palate impressions in infants.
Shatkin and stark described the use of a wax as impression trays in cleft lip and palate patients.
Icecream sticks can also be used to carry materials for infant impressions.
The prosthetic treatment in infants includes--
Improve feeding Tongue function Speech development
It reduces the risk of aspiration the as oro-nasal communication is eliminated and it is an easier procedure with good aesthetic results.
Prosthetic care for infants
Feeding obturator
Feeding plate obturates cleft and restores the separation between oral and nasal cavities.
It aid in creating sufficient negative pressure which allows adequate sucking of milk and creates a rigid platform towards which baby can press nipple and extract milk.
Feeding appliances
It facilitates feeding by –
• Reduces the nasal regurgitation .
• Reduces the incidence of choking and shortens the length of time required for feeding.
• It restore the basic function of mastication , Deglutition , speech production until cleft lip or palate can be surgically corrected.
Primary impression was made with molding with low fusion impression compound with hand adaptation to the palate of the patient.
The infant was held upright by mother to prevent aspiration of any extra material.
Primary cast was fabricated by dental stone( type 3 gypsum product )
Fabrication of feeding plate
Showing the primary impression
A customized special tray fabricated by auto polymerizing acrylic resin.
The final impression made by rubber base impression material to record the precise detail of supporting structure and defect.
Customized special tray
Final impression
Master cast fabricated and excessive undercuts blocked out with modeling wax.
Wax pattern of the feeding plate adapted on master cast. Flasking , de-waxing done and feeding plate fabricated with heat activated clear acrylic for obturating the defect in the soft palate involving uvula.
Master cast with block out
Palatal plate on master cast
Palatal plate with thread
Feeding plate
Extra oral view
Intraoral view
Tooth replacement
Options for tooth replacement includes--
Fixed or removable partial
dentureComplete denture Dental implants
Impression materials used for young patient
Elastomeric impression
material
Irreversible hydrocolloids
Due to alteration of alveolar ridge of individuals with cleft lip and palate patient, the rehabilitation with complete denture is challenging to dentist.
Complete denture
Denture stability
Physical factors
Retention
Difficulties are --
Unrepaired clefts
Presence of fistula
Alveolar ridge anato
my
Open ridges with wide cleft
Impression
Anatomical
Functional Stock tray
Addition
Condensation silicon
In case fistula
present or not
Impression
Anatomical Functional
Stock tray Fistula absent
Fistula present
High fusing impression compound
High fusing impression compound
A removal partial denture is most often used but it is a temporary form of tooth replacement.
R.P.D are especially indicated in patients with tissue deficiency several fistulas, soft palate dysfunction or uncoordinated nasopharyngeal sphinctor action.
Removable partial dentures
Although it provide good esthetics , it rests on soft tissue of the palate and causes irritation.
Planning of R.P.D should be combined to clinical & radiographic examination & dental cast analysis and occlusal analysis and determination of site of retainer , connector and dental bar.
There may be movement of the prosthesis during function. Hence it is used only as a definitive means of tooth replacement in which multiple teeth are missing and the edentulous space is too long to be spanned by a fixed restoration and when patient cannot afford implants.
A fixed partial denture attaches to teeth on each side of edentulous space to provide a more natural tooth replacement
If the abutment teeth need no other restoration then a resin bonded fixed
Fixed partial denture
It provides a more natural tooth replacement. Whenever , possible conservative , i.e. resin
bonded fixed partial denture should be provided for anterior replacement only.
This conservative restoration requires very little tooth preparation, and provides excellent appearance and function.
Alternatively , a conventional fixed partial denture can be used. This provides long – term success.
Conclusion Prosthodontist are one of member of multi
disciplinary cleft team. In the care of patient with cleft lip and palate
prosthetic treatment retains an important place.
Prosthodontist must be able to diagnosis the defect and provide a preventive, interventional and rehabilitative treatment to reduce the impact of the defect in patient quality of life.
Maxillofacial rehabilitation : Prosthodontic and surgical considerations by Beumer.
Clinical maxillofacial prosthetics by Taylor.
Dentistry for the child and adolescent by Mc’donald and Averys 9th edition.
Textbook of Pediatric dentistry :by Damle. 2nd edition.
Textbook of Pediatric dentistry by Nikhil Marwah 2nd edition.
Internet.
References
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