|Year : 2022 | Volume
| Issue : 2 | Page : 189-196
Prosthetic rehabilitation of patients with cleft lip and palate
Veerendra Prasad1, Lobsang Chhodon1, A Aravindhan2, S Javed Akhter Zaidi1
1 Department of Plastic Surgery, K.G.M.U, Lucknow, Uttar Pradesh, India
2 Department of Paediatric and Preventive Dentistry, K.G.M.U, Lucknow, Uttar Pradesh, India
|Date of Submission||17-Mar-2022|
|Date of Acceptance||26-May-2022|
|Date of Web Publication||23-Aug-2022|
Dr. Lobsang Chhodon
Department of Plastic Surgery, K.G.M.U, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Orofacial anomalies are common of which the most common orofacial deformity is cleft lip and palate (CLP), which affects one out of every 700–1000 infants globally. The management team should provide a thorough diagnosis, treatment plan, and follow-up. A cleft team often includes orthodontists, maxillofacial surgeons, plastic surgeons, pediatric dentists, prosthodontists, speech therapists, audiologists, psychologists, and pediatricians. Prosthetic rehabilitation of the CLP patients starts right from birth to adulthood. It varies from the naso alveolar molding of cleft segments before surgery and expansion of maxillary arch before the secondary alveolar bone grafting to the placement of fixed partial dentures or removable partial dentures for the establishment of better esthetics. A soft-tissue bulb prosthesis can also be given to children with velopharyngeal insufficiency to improve their speech. This article elucidates prosthetic rehabilitation techniques and modalities for patients with CLP.
Keywords: Cleft lip and palate, fixed partial dentures, maxillary expansion, naso alveolar molding, prosthetic rehabilitation, speech bulb prosthesis
|How to cite this article:|
Prasad V, Chhodon L, Aravindhan A, Zaidi S J. Prosthetic rehabilitation of patients with cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2022;9:189-96
|How to cite this URL:|
Prasad V, Chhodon L, Aravindhan A, Zaidi S J. Prosthetic rehabilitation of patients with cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Dec 8];9:189-96. Available from: https://www.jclpca.org/text.asp?2022/9/2/189/354297
| Introduction|| |
Orofacial anomalies are common of which the most common orofacial deformity is cleft lip and palate (CLP), affecting one out of every 700–1000 infants globally. It can occur alone, in various combinations, and/or in conjunction with other congenital malformations, such as congenital heart disease. A bilateral cleft lip is more common in males than in females (male-to-female ratio 2:1), but a cleft palate is more common in females. There is a higher prevalence of cleft deformities in Asian and Latino populations, followed by some Native American groups, with African American having the lowest rate. The absence of continuity of tissues composing the lip, alveolus, and soft and hard palate is a characteristic of the abnormality. It varies in severity from a small cut on the lip to a large fissure extending into the roof of the mouth and nose. The purpose of this article is to discuss prosthetic rehabilitation in people with CLP.
| Background|| |
Children with CLP should be managed by a multidisciplinary team that can provide the best possible care. In addition to diagnosis, treatment, and follow-up, the management team should provide comprehensive guidance. The orthodontist, maxillofacial surgeon, plastic surgeon, pediatric dentist, prosthodontist, speech therapist, audiologist, psychologist, and pediatrician are frequently on the cleft team. Treatment should aim to repair the birth defect (lip, palate, and nose), to enhance speech, language, hearing, and dental health in children with CLP. In addition, it should improve psychological and developmental well-being.
| Infant Phase|| |
For centuries, presurgical infant orthopedics has been commonly used to treat CLP patients. McNeil is attributed for developing an intraoral device to realign cleft alveolar segments. Feeding difficulties are likely to be the most immediate concern induced by orofacial clefting as it delays normal growth. The anatomical features of CLP make it difficult for newborns to feed. Choking, milk ejection through the nose, and excessive air intake can all result from poor intraoral suction. For parents of such infants, the feeding process can be challenging, as they typically struggle to find an effective feeding method. A special dental palatal prosthesis can be installed to seal the cleft side. In newborns with CLP, such a prosthesis could help increase fluid intake, reduce feeding time, and promote optimal growth and weight gain which is required for the reconstructive surgical procedures in the first few months of life. The oral and nasal cavity is separated by a feeding plate which reduces the nasal regurgitation and thus creates a negative pressure required for sucking.
The nasolabial and maxillary segments are being repositioned closer to each other, mainly during the first few weeks after birth and in the months prior to palate repair. Prior to surgery, presurgical orthopedic therapy generally entails active movement of the maxillary fragments using passive or active alveolar plates.
The Latham appliance is an active presurgical orthopedic device. Its long-term consequences are subject to debate. The primary idea behind the appliance is to reduce the anatomical problem of cleft deformity to have a better surgical outcome. The device is effective in expanding and aligning maxillary segments, retruding protruded premaxilla, aligning bilateral alveolar ridges, reducing tension on surgical closures, and lowering fistula rates. Its long-term impact on maxillary development or occlusion, however, has yet to be established. Whenever a nasal stent is added to the alveolar plate, it is considered nasoalveolar molding (NAM).
The advantage of the presurgical NAM (PNAM) device is that it not only serves as a molding device but also serves as a feeding plate, facilitating newborn feeding and assisting in the establishment of the essential suckling reflex.
| Nasoalveolar Molding|| |
In 1993, Grayson adopted the nasal stent of Matsuo to extend from the anterior flange of an intraoral molding plate. This new technique was called NAM to correct the alveolus, lip, and nose in infants born with CLP.
The principal objective of PNAM is to lessen the severity of the initial cleft deformity. This provides the surgeon with the benefits of repairing a child with a minimal cleft deformity. Uprighting of the columella, and reduction in the width of the alveolar cleft segments until passive contact of the gingival tissues is achieved are among these objectives. The base of the nose and lip segments align better as the alveolar gap width is reduced.
PNAM, on the other hand, can reduce soft tissue and cartilaginous cleft deformity, allowing for surgical soft tissue repair with less strain and scar formation.
- It accelerates and redirects alveolar segment growth, resulting in optimal arch formation
- Furthermore, appropriately placing the tongue, aids in normal speech development.
NAM was found to be beneficial in nasolabial form when compared with no appliance-based presurgical treatment in cleft patients.
A removable alveolar molding plate composed of orthodontic acrylic makes up the PNAM device [Figure 1]. The nasal stent is bent at the end of a 0.032-inch stainless steel wire that is embedded into the anterior portion of the alveolar molding plate [Figure 2]. To gradually correct nasal and alveolar abnormalities, the nasal stent and intraoral molding plate are adjusted weekly or biweekly.
A heavy-bodied silicone impression material is used to take the initial impression as soon as feasible after birth as the cartilage is plastic and moldable [Figure 3]. The surgeon is always on hand to assist with the impression in the event of an airway emergency.
- The surgeon holds the infant upside down while inserting the impression tray into the mouth cavity
- The tray is seated until the impression material begins to extrude past the tray's posterior border. To keep the tongue forward and allow fluids to flow out of the mouth cavity, the infant is maintained inverted
- Once the impression material has been set, the tray is removed, and the mouth is checked for any leftover impression material
- A model or a positive replica of the alveolar anatomy is made by dental stone [Figure 4] to fabricate the molding plate
- The molding plate is made of hard clear acrylic with a thin coating of soft denture material on the inside [Figure 2]. The border of the plate is carefully reduced in the area of the labial frenum attachments and other locations that are prone to ulceration
- Parents are instructed to keep the plate full time and to clean it at least once a day.
The retentive component of the nasal stent was acralysed in the plate during plate construction using 032-inch titanium molybdenum alloy wire. The plate is placed in the infant's mouth, and a 3–4 mm diameter coil is formed from the wire.
The traditional method of two-dimensional analysis provides incomplete data, and it does not account for differences in depth and shape. Thus, Yu et al. modified the traditional NAM therapy with computer-aided design (CAD) technology in patients with unilateral CLP (UCLP).
Three-dimensional data is acquired through a rapid-measuring noncontact three-dimensional laser scanner preoperatively. Based on a computer-aided reverse engineering system, a set of appliances is designed and fabricated using the rapid prototyping technique. A series of molding plates are printed and delivered to the parents at every visit. As weekly visits for PNAM treatment are inconvenient for CLP families in remote regions, hence the follow-up visits are monthly in CAD NAM.
| Childhood Phase|| |
By the age of three, the primary dentition has erupted and a definitive occlusal relationship has been formed. Most patients with complete cleft palates will require orthodontic treatment. At this point, the emphasis is on arch alignment rather than tooth alignment to improve occlusal function and promote a more favorable maxillo-mandibular dental relationship when permanent teeth emerge. Arch alignment and speech assistance through the closure of nasoalveolopalatal fistulas and the use of a pharyngeal obturator are the primary indications for a prosthesis at this stage.
| Expansion Appliance|| |
The cleft compromises the structural integrity of the palate and alveolus as seen in [Figure 5], causing the minor segment of the maxilla to rotate mediolingually. The collapsed minor segment is a typical clinical characteristic in patients with UCLP, and it is hypothesized to be caused by the surrounding face soft tissues shaping the minor segment. It often results in constricted maxillary/palatally arch [Figure 6].
In CLP patients, maxillary transverse deficiency is common, and it may be treated with either slow maxillary expansion (Quad helix, NiTi palatal expander) or rapid maxillary expansion (Hyrax). The palatal suture system is disrupted in CLP individuals, and it is either irregular or absent. Because of the unique anatomical condition in the jaw and palate area, skeletal resistance in the transverse direction is reduced in cleft palate patients. According to Vasant MR, both the Quad helix and the rapid palatal expander (RPE) appliance can expand the maxilla and correct posterior crossbites in CLP patients. The expansion occurs by increasing the distance between the cleft segments. The Quad helix expansion appliances can correct rotated molars whereas, the RPE appliance does not.
In the deciduous dentition, a removable expansion plate with a jackscrew [Figure 7] can be used to expand the arch as well as to correct the crossbite. It can also serve as an obturator in patients with oro-nasal fistulas. The parent can be instructed to turn the adjustment screw to keep the force of the prosthesis active.
The basic need for expansion includes alignment for collapsed arches, correction of cross-bites, expanding and aligning the arch to prepare them for ABG (alveolar bone graft), improving airway dimensions after expansion, and facilitating nasal expansion, as well as preparing them to aid in maxillary protraction.
| Soft Tissue Bulb|| |
Velopharyngeal insufficiency (VPI) occurs when the soft palate does not close completely against the pharyngeal wall during speech and swallowing, causing regurgitation into the nasal cavity and hypernasal speech. This could cause eating, breathing, and speech problems. When the surgically repaired soft palate is too short to make touch the pharyngeal walls during function, a speech prosthesis or speech bulb is the best option.
Speech therapy, surgery, a prosthesis, or a combination of treatments may be used to treat VPI. Prostheses are essential to therapy choices for velopharyngeal dysfunction, even though palatoplasty and pharyngoplasty are more commonly employed. The speech prosthesis may be the best option in a variety of scenarios, such as when surgery is not possible due to systemic, anatomic, or functional restrictions, or when the patient refuses surgery.
The bulb fills up the pharyngeal space caused by velopharyngeal opening during speaking when the velum is short in comparison to the depth of the posterior pharyngeal wall. During the speech, the bulb is positioned in the nasopharynx to occlude the velopharyngeal port. Because nasal regurgitation is eliminated, this improves speech and may help improve swallowing. To fit behind the velum in the nasopharynx, the bulb curves upward.
Speech prosthesis consists of • Palatomaxillary anterior section • Palatovelar middle section • Nasopharyngeal posterior section– Speech bulb [Figure 8].
Palatomaxillary section (anterior)
The palatomaxillary segment improves the appearance of the individual by integrating missing teeth and stabilizing the free-floating pre-maxilla. This section's role is to keep the appliance firmly in place against the roof of the mouth. It can also be used as an obturator to close a palate defect.
Palatovelar section (middle)
A connecting link between the maxillary and nasopharyngeal sections is the palatovelar segment. The width and thickness of the appliance vary according to whether the soft palate is operated or not. This component of the appliance must be thick enough to interfere with speech production.
Nasopharyngeal section (posterior)
The nasopharyngeal part should be large enough to establish a velopharyngeal seal during phonation and swallowing, but should not block the nasal passages. Because the posterior and lateral pharyngeal musculature comes into contact with this area during swallowing and phonation, it should be well tolerated by tissue i.e., nonirritating and clean. The palatal lift and speech bulb appliances are meant to close the middle region of the velopharyngeal port so that the lateral pharyngeal walls can be more effective in achieving closure during the speech.
| Adult PhasE|| |
Achieving esthetic outcomes is challenging in cleft patients because the presence of lip frenula, deficiency of bone tissue, and keratinized mucosa can pose serious problems for the maintenance of the prosthetic work. Preservation of remaining structures is as important as the replacement of mixing structures. The success of any fixed or removable partial prosthesis depends on the maintenance of natural teeth. Since the remaining teeth usually must resist more stress, including the adjacent teeth for wide distribution is important.
Fixed partial dentures (FPD), removable partial dentures (RPD), overlay dentures, complete dentures, and implant-supported dentures are the most common prosthetic treatments used in the oral rehabilitation of people with CLP [Figure 9] and [Figure 10].
| Fixed Partial Denture|| |
Sound prosthetic principles must be followed while employing a FPD, especially when dealing with cleft-palate patients. Teeth adjacent to the cleft usually have inadequate bony support on the side facing the defect. The lack of support weakens the tooth as an abutment. To prevent the FPD from failing, one extra tooth on each side of the cleft is usually required.
The denture should be strong enough to withstand any abnormal stresses and strains it may be subjected to, and it should compensate for anatomic defects in the cleft so that the lips are correctly supported and speech is normal.
In comparison to traditional fixed dental prosthesis, the extended embrasures around the abutment adjacent to the remaining fistula covered by removable attachment retained gingival veneer allow hygienic maintenance. Because the gingival margins of adjacent abutments were not at the same level, gingival porcelain might be added to the final prosthesis to improve the aesthetics.
To compensate for the bone abnormality, the tooth length was adjusted for cosmetic purposes by adding pink porcelain to the cervical section of the construction above the alveolar ridge.
| Removable Partial Denture|| |
In individuals with CLP, the bony structure does not always allow for the indication of an appropriate therapy with fixed or implant-supported dentures. Thus, RPD have been an essential treatment choice for people with CLP.
RPD planning should be integrated with clinical and radiographic evaluations, as well as the study of dental casts. The surveyor analysis is necessary to account for changes in tooth anatomy to improve denture retention. The RPDs are also advised for palate closure in circumstances where surgical repair is not possible.
| Overlay Denture|| |
This resource is indicated basically for individuals with CLP, in extreme cases, with hypoplasia and marked retrusion of the maxilla with tooth loss and/or malpositioning when it was not possible to indicate orthodontic treatment and orthognathic surgery. This is not the ideal prosthetic solution, yet it allows the completion of clinical cases with lip support and favorable vertical dimension.
- Lack of vertical, lateral, and anteroposterior growth due to resected premaxilla
- Floating premaxilla in abnormal relationship
- Patients exhibiting lip collapse and postoperative lip tightness and/or tenseness
- Patients having few remaining teeth in an abnormal or collapsed occlusal relationship
- Large anterior ridge defect associated with depression of the middle third of the face
- In unilateral cases, the overlay partial denture is indicated with the flange confined to the cleft side of the arch.
| Implant-Supported Denture|| |
Prosthetic rehabilitation with implant-supported overdenture and an implant-supported fixed denture is, in some situations, the only option in edentulous patients with CLP as it has better retention, stability, and masticatory efficiency compared to conventional dentures. The appropriate time for implant placement in most CLP patients is after completion of the growth period and around 4–6 months after bone grafting. The implant-supported fixed denture requires more bone because more implants are installed. If the patient has an insufficient support lip, a high smile line, or a prognathic look that needs to be compensated, implant-supported overdenture is the best option.
| Andrews Bridge|| |
Conventional FPDs and implant-supported FPD fail to replace the lost soft tissue structures. In such cases, the replacement of teeth along with the supporting structures can be achieved by Andrew's Bridge.
Andrew's bridge system is composed of two components: A fixed component (retainers on abutments joined by the bar) and a removable component. the support mechanism is shared by the tooth, and the tissues to some extent, and the bar serve as a retentive and stabilizing tool for the removable segment. The Andrew's bridge permits rehabilitation in cleft-palate patients with congenital or acquired defects when conventional methods are contraindicated. It permits the replacement of the lost teeth and supportive structures.
| Conclusion|| |
Individuals with CLP frequently require a multidisciplinary approach. A cleft team includes audiologists, nursing teams, orthodontists, maxillofacial surgeons, plastic surgeons, pediatric dentists, prosthodontists, speech therapists, psychologists, and pediatricians. It is best to treat a cleft patient when he is young rather than when he is older. Treating such patients not only restores their physical appearance, but also gives them a better beginning.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Murray JC. Gene/environment causes of cleft lip and/or palate. Clin Genet 2002;61:248-56.
Shkoukani MA, Chen M, Vong A. Cleft lip – A comprehensive review. Front Pediatr 2013;1:53.
Lewis CW, Jacob LS, Lehmann CU. The primary care pediatrician and the care of children with cleft lip and/or cleft palate. Pediatrics 2017;139:e20170628.
Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, Harland K. Palate re-repair revisited. Cleft Palate Craniofac J 2002;39:295-307.
McNeil CK. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec (London) 1950;70:126-32.
Turner C, Zagirova AF, Frolova LE, Courts FJ, Williams WN. Oral health status of Russian children with unilateral cleft lip and palate. Cleft Palate Craniofac J 1998;35:489-94.
Alzain I, Batwa W, Cash A, Murshid ZA. Presurgical cleft lip and palate orthopedics: An overview. Clin Cosmet Investig Dent 2017;9:53-9.
Cruz C. Presurgical orthopedics appliance: The Latham technique. Oral Maxillofac Surg Clin North Am 2016;28:161-8.
Subramanian CS, Prasad NK, Chitharanjan AB, Liou EJ. A modified presurgical orthopedic (nasoalveolar molding) device in the treatment of unilateral cleft lip and palate. Eur J Dent 2016;10:435-8.
] [Full text]
Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 1993;92:1422-3.
Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Semin Plast Surg 2005;19:294-301.
Attiguppe PR, Karuna YM, Yavagal C, Naik SV, Deepak BM, Maganti R, et al.
Presurgical nasoalveolar molding: A boon to facilitate the surgical repair in infants with cleft lip and palate. Contemp Clin Dent 2016;7:569-73.
] [Full text]
Padovano WM, Skolnick GB, Naidoo SD, Snyder-Warwick AK, Patel KB. Long-term effects of nasoalveolar molding in patients with unilateral cleft lip and palate: A systematic review and meta-analysis. Cleft Palate Craniofac J 2022;59:462-74.
Grayson BH, Garfinkle JS. Early cleft management: The case for nasoalveolar molding. Am J Orthod Dentofacial Orthop 2014;145:134-42.
Yu Q, Gong X, Wang GM, Yu ZY, Qian YF, Shen G. A novel technique for presurgical nasoalveolar molding using computer-aided reverse engineering and rapid prototyping. J Craniofac Surg 2011;22:142-6.
Zheng J, He H, Kuang W, Yuan W. Presurgical nasoalveolar molding with 3D printing for a patient with unilateral cleft lip, alveolus, and palate. Am J Orthod Dentofacial Orthop 2019;156:412-9.
Brasil JM, de Almeida Pernambuco R, da Silva Dalben G. Suggestion of an oral hygiene program for orthodontic patients with cleft lip and palate: Findings of a pilot study. Cleft Palate Craniofac J 2007;44:595-7.
Sehrawat R, Malik P, Rathee M, Kaur B. Rehabilitation of cleft lip and palate patients with a systematic approach. Med Res Chron 2015;2:572-8.
Subtelny JD, Brodie AG. An analysis of orthodontic expansion in unilateral cleft lip and cleft palate patients. Am J Orthod 1954;40:686-97.
Levitt T, Long RE Jr., Trotman CA. Maxillary growth in patients with clefts following secondary alveolar bone grafting. Cleft Palate Craniofac J 1999;36:398-406.
Vasant MR, Menon S, Kannan S. Maxillary expansion in cleft lip and palate using quad helix and rapid palatal expansion screw. Med J Armed Forces India 2009;65:150-3.
Jain S, Shrivastav S, Jain NK. Maxillary expansion in cleft lip and palate cases – A review. Int J Adv Res 2015;3:1455-61.
Pinto JH, da Silva Dalben G, Pegoraro-Krook MI. Speech intelligibility of patients with cleft lip and palate after placement of speech prosthesis. Cleft Palate Craniofac J 2007;44:635-41.
Freitas JA, Almeida AL, Soares S, Neves LT, Garib DG, Trindade-Suedam IK, et al.
Rehabilitative treatment of cleft lip and palate: Experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) – Part 4: Oral rehabilitation. J Appl Oral Sci 2013;21:284-92.
Dhakshaini MR, Pushpavathi M, Garhnayak M, Dhal A. Prosthodontic management in conjunction with speech therapy in cleft lip and palate: A review and case report. J Int Oral Health 2015;7:106-11.
Lopes JF, Pinto JH, de Almeida AL, Lopes MM, da Silva Dalben G. Cleft palate obturation with Brånemark protocol implant-supported fixed denture and removable obturator. Cleft Palate Craniofac J 2010;47:211-5.
Immekus JE, Aramany M. A fixed-removable partial denture for cleft-palate patients. J Prosthet Dent 1975;34:286-91.
Geethu RM, Anilkumar S. Esthetic and functional rehabilitation of an adult cleft lip and palate patient using combined fixed and removable prosthesis. J Interdiscip Dent 2018;8:35-40.
Titiz S, Çelikkol O, Ateş P, Aras A, Erverdi N. Multidisciplinary treatment of two patients with cleft lip and palate using archwise distraction: A case report. J Stomatol Oral Maxillofac Surg 2019;120:61-6.
Mazaheri M. Indications and contraindications for prosthetic speech appliances in cleft palate. Plast Reconstr Surg Transplant Bull 1962;30:663-9.
Rothenberg LI. Overlay dentures for the cleft-palate patient. J Prosthet Dent 1977;37:327-9.
Zanolla J, Amado FM, da Silva WS, Ayub B, de Almeida AL, Soares S. Success rate in implant-supported overdenture and implant-supported fixed denture in cleft lip and palate patients. Ann Maxillofac Surg 2016;6:223-7.
] [Full text]
Wermker K, Jung S, Joos U, Kleinheinz J. Dental implants in cleft lip, alveolus, and palate patients: A systematic review. Int J Oral Maxillofac Implants 2014;29:384-90.
Zitzmann NU, Marinello CP. Treatment plan for restoring the edentulous maxilla with implant-supported restorations: Removable overdenture versus fixed partial denture design. J Prosthet Dent 1999;82:188-96.
Chaudhary R, Kumar D, Khattak A, Yadav RK, Gopi A, Sharma D. Prosthodontic Rehabilitation of a Cleft Patient with Andrews Bridge: A Case Report. Int J Oral Dent Health. 2020;6:107.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]