Opening New Horizons and Opening New Horizons and Creating a Normal, Creating a Normal,

Functional Life for Cleft Functional Life for Cleft Palate PatientsPalate Patients

ByBy

Tanja GeurtseTanja GeurtseIn partial fulfilment of In partial fulfilment of

BTech: Den Tech. DegreeBTech: Den Tech. DegreeSeptember 2004September 2004

ContentContent

•Patient historyPatient history•Condition and backgroundCondition and background•Possible treatment optionsPossible treatment options•Treatment option most suitableTreatment option most suitable•Treatment option of choiceTreatment option of choice•Laboratory proceduresLaboratory procedures•ReferencesReferences

HistoryHistory

1996 Consultation at Tygerberg Hospital1996 Consultation at Tygerberg Hospital 26 year old female26 year old female Cleft palate Cleft palate Severe Class 3 biteSevere Class 3 bite Severe occlusal abnormalitiesSevere occlusal abnormalities Unknown syndromeUnknown syndrome Poor oral hygienePoor oral hygiene Difficult at chair sideDifficult at chair side Appliances breakAppliances break

Le fort 1 OsteotomyLe fort 1 Osteotomy Correct occlusal abnormalitiesCorrect occlusal abnormalities Followed up with halo frame (8 weeks)Followed up with halo frame (8 weeks) Followed up with an orthodontic deviceFollowed up with an orthodontic device Maintains occlusion (2 months)Maintains occlusion (2 months) Acrylic resin interim obturatorAcrylic resin interim obturator55

Condition and BackgroundCondition and Background

Condition and Background Condition and Background cont.cont.

Bilateral saggital splitBilateral saggital split GenioplastyGenioplasty Acrylic mandibular removable partial dentureAcrylic mandibular removable partial denture

Possible Treatment Possible Treatment OptionsOptions

Maxilla:Maxilla: Acrylic Pharyngeal obturatorAcrylic Pharyngeal obturator Cobalt chromium Pharyngeal obturatorCobalt chromium Pharyngeal obturator

Mandible:Mandible: Implant supported crowns Implant supported crowns Acrylic Removable partial denture Acrylic Removable partial denture Cobalt chromium removable partial dentureCobalt chromium removable partial denture

Cobalt chromium Pharyngeal Cobalt chromium Pharyngeal Obturator Obturator

Advantages:Advantages: Acts as speech aidActs as speech aid Palatopharyngeal closurePalatopharyngeal closure Prevents nasal leakagePrevents nasal leakage Enhances breathingEnhances breathing Enhances swallowingEnhances swallowing Very strongVery strong66

Cobalt chromium Pharyngeal Cobalt chromium Pharyngeal Obturator Obturator cont.cont.

Disadvantages:Disadvantages: Large obturator weightLarge obturator weight Stress on abutment teethStress on abutment teeth Lack of posterior teeth, compromises successLack of posterior teeth, compromises success77

Difficult to adjustDifficult to adjust Requires long, parallel guide planes on abutment teeth Requires long, parallel guide planes on abutment teeth

for retention and stabilityfor retention and stability More difficult to fabricateMore difficult to fabricate66

AcrylicAcrylic Pharyngeal ObturatorPharyngeal Obturator

Advantages:Advantages: Improves palatopharyngeal Improves palatopharyngeal

incompetenceincompetence Acts as speech aidActs as speech aid Improves speech disordersImproves speech disorders Enhances swallowingEnhances swallowing Enhances normal breathingEnhances normal breathing Prevents nasal leakagePrevents nasal leakage Easy to adjustEasy to adjust Easier to fabricate than cobalt chromium R.P.DEasier to fabricate than cobalt chromium R.P.D66

AcrylicAcrylic Pharyngeal Obturator Pharyngeal Obturator cont.cont.

Disadvantages:Disadvantages:

Not a panacea for hypernasal speechNot a panacea for hypernasal speech Discomfortable and bulkyDiscomfortable and bulky Too heavyToo heavy DislodgementDislodgement Acrylic not strong in thinner areasAcrylic not strong in thinner areas Clasp arms bend easyClasp arms bend easy Clasp arms can be annealed mechanicallyClasp arms can be annealed mechanically Loss in flexibilityLoss in flexibility Reduced strengthReduced strength66

Implant Supported CrownsImplant Supported Crowns

Advantages:Advantages: Improves aestheticsImproves aesthetics Less pressure on frontal plateLess pressure on frontal plate StableStable DurableDurable66

Implant Supported Crowns Implant Supported Crowns cont.cont.

Disadvantages:Disadvantages: Requires patient responsibilityRequires patient responsibility Possible failurePossible failure Operation requiredOperation required Higher cost than previous options Higher cost than previous options

(R 6200)(R 6200)

Acrylic Removable Partial Acrylic Removable Partial

DentureDenture Advantages:Advantages:

Easy:Easy:

-to clean and maintain-to clean and maintain

-repair and adjust-repair and adjust Not as expensive as implants (R1 200)Not as expensive as implants (R1 200) Simple to design and fabricateSimple to design and fabricate

Acrylic Removable PartialAcrylic Removable Partial Denture Denture cont.cont.

Disadvantages:Disadvantages: Acrylic not strong in thin areasAcrylic not strong in thin areas Too bulkyToo bulky Not stableNot stable DislodgeDislodge Clasp arms bend easyClasp arms bend easy Clasp arms can be annealed mechanicallyClasp arms can be annealed mechanically Loss in flexibilityLoss in flexibility Implants have better aestheticsImplants have better aesthetics

Cobalt Chromium Removable Cobalt Chromium Removable Partial DenturePartial Denture

Advantages:Advantages: Very strongVery strong Less bulkyLess bulky Easy to cleanEasy to clean Doesn’t impinge on tongue spaceDoesn’t impinge on tongue space

Cobalt Chromium Removable Cobalt Chromium Removable Partial DenturePartial Denture cont.cont.

Disadvantages:Disadvantages: May bruise bulky tissueMay bruise bulky tissue More difficult to fabricate More difficult to fabricate Small applianceSmall appliance Can be swallowed easilyCan be swallowed easily

Treatment option most suitableTreatment option most suitable

Acrylic Pharyngeal ObturatorAcrylic Pharyngeal ObturatorReasons for choice:Reasons for choice:

Improves palatopharyngeal incompetenceImproves palatopharyngeal incompetence Acts as speech aidActs as speech aid Improves speech disordersImproves speech disorders Enhances swallowingEnhances swallowing Enhances normal breathingEnhances normal breathing Prevents nasal leakagePrevents nasal leakage Easy to adjustEasy to adjust Easier to fabricate than cobalt chromium R.P.DEasier to fabricate than cobalt chromium R.P.D66

Treatment option most suitable Treatment option most suitable and of choice and of choice

MandibleMandible

Chrome Cobalt Removable Partial DentureChrome Cobalt Removable Partial Denture Reasons for choice:Reasons for choice:

Very strongVery strong Less bulkyLess bulky Easy to cleanEasy to clean Doesn’t impinge on tongue spaceDoesn’t impinge on tongue space

Treatment Option of Choice Treatment Option of Choice

MaxillaMaxilla Cobalt chromium Pharyngeal ObturatorCobalt chromium Pharyngeal Obturator

Reasons for choice:Reasons for choice:

Stronger than acrylic obturatorStronger than acrylic obturator Improves palatopharyngeal incompetenceImproves palatopharyngeal incompetence Enhances swallowingEnhances swallowing Enhances normal breathing Enhances normal breathing Increased retention, support and stabilityIncreased retention, support and stability Light in weightLight in weight66

Laboratory ProceduresLaboratory Procedures

Receive impressionsReceive impressions Pour primary modelsPour primary models Special traySpecial tray Pour secondary modelsPour secondary models Duplicate model (Agar)Duplicate model (Agar)

Laboratory ProceduresLaboratory Procedures cont.cont.

Wax up maxillary obturator:Wax up maxillary obturator: Full palatal major connectorFull palatal major connector Two clasps with rests on the 2.4&1.7Two clasps with rests on the 2.4&1.7 Roach clasp with rest on the 1.3Roach clasp with rest on the 1.3 Saddle areas for acrylic teethSaddle areas for acrylic teeth Extension to close the cleftExtension to close the cleft

Laboratory Procedures cont.Laboratory Procedures cont.

Invest wax pattern Invest wax pattern Cast framework Cast framework Metal framework divested, trimmed and Metal framework divested, trimmed and

finishedfinished Wax up with acrylic teethWax up with acrylic teeth Try inTry in InvestedInvested Packed with acrylicPacked with acrylic CuredCured Divested, trimmed and finishedDivested, trimmed and finished

Laboratory Procedures cont.Laboratory Procedures cont.

Laboratory ProceduresLaboratory Procedures cont.cont.

Severe undercutsSevere undercuts Wax up mandibular Wax up mandibular

obturator:obturator: Lingual bar becomes Lingual bar becomes

labial and buccal barlabial and buccal bar Buccal bracing armsBuccal bracing arms Lingual retentive armsLingual retentive arms Ackers clasp and restsAckers clasp and rests

-Extended to 4.5 and 4.6-Extended to 4.5 and 4.6 Ackers clasp and restsAckers clasp and rests

-Extended to 3.6 and 3.7-Extended to 3.6 and 3.7 Eliminates accidental Eliminates accidental

swallowingswallowing

Laboratory Procedures cont.Laboratory Procedures cont.

Invest wax patternInvest wax pattern Cast frameworkCast framework Metal framework divested, trimmed and finishedMetal framework divested, trimmed and finished Wax up with acrylic teethWax up with acrylic teeth Try inTry in InvestedInvested Packed in heat cured acrylicPacked in heat cured acrylic CuredCured Divested, trimmed and finishedDivested, trimmed and finished

ReferencesReferences

1.1. Booth P W, Eppley B L, Schmelzeisen R. Booth P W, Eppley B L, Schmelzeisen R. Maxillofacial Trauma Maxillofacial Trauma and Aesthetic Facial Reconstruction. and Aesthetic Facial Reconstruction. London:Churchill London:Churchill Livinstone. 2003: 237.Livinstone. 2003: 237.

2.2. Booth P W, Eppley B L, Schmelzeisen R. Booth P W, Eppley B L, Schmelzeisen R. Maxillofacial Trauma Maxillofacial Trauma and Aesthetic Facial Reconstruction. and Aesthetic Facial Reconstruction. London:Churchill London:Churchill Livinstone. 2003: 477-478.Livinstone. 2003: 477-478.

3.3. Branemark P, Tolman D E. Branemark P, Tolman D E. Osteointergration in Craniofacial Osteointergration in Craniofacial Reconstruction.Reconstruction. London: Quintessence Publishing Co, Inc. London: Quintessence Publishing Co, Inc. 1998: 56.1998: 56.

4.4. Kernahan D A, Rosenstein S W. Cleft Lip and Palate: Kernahan D A, Rosenstein S W. Cleft Lip and Palate: A System A System of Management.of Management. London: Williams & Wilkins. 1990:1-256. London: Williams & Wilkins. 1990:1-256.

5.5. Taylor TD. Taylor TD. Clinical Maxillofacial Prosthetics.Clinical Maxillofacial Prosthetics. London: London: Quintessence Publishing Co, Inc. 2000:121-130.Quintessence Publishing Co, Inc. 2000:121-130.

6.6. Taylor TD. Taylor TD. Clinical Maxillofacial Prosthetics.Clinical Maxillofacial Prosthetics. London: London: Quintessence Publishing Co, Inc. 2000:134-138.Quintessence Publishing Co, Inc. 2000:134-138.