Prosthodontic management of cleft lip and palate

PROSTHODONTIC MANAGEMENT
OF CLEFT LIP AND PALATE
BY,
PAAVANA
III MDS

• INTRODUCTION
• HISTORY
• DEFINITION
• EMBRYOLOGY
• RISK FACTORS
• EPIDEMIOLOGY
• CLASSIFICATION OF CLEFT LIP AND PALATE
• DISABILITIES CAUSED BY THE PRESENCE OF A CLEFT PALATE
• ROLE OF PROSTHODONTISTS IN REHABILITATION
• INDICATIONS AND CONTRAINDIICATIONS FOR PROSTHESIS
• SELECTION CRITERIA FOR PROSTHODONTIC REHABILITATION
• PROSTHETIC REHABILITATION OF CLEFT PALATE PATIENTS
• COMMON ERRORS IN THE CLINICAL MANAGEMENT OF CONGENITAL DEFECTS
• CONCLUSION
• REFERENCES
2
CONTENTS

INTRODUCTION
ORAL
REHABILITATION
FUNCTIONAL ANATOMIC
3

HISTORY
4
First obturation of a cleft palate was performed by Demosthenes
(384–323 BC).
Bien suggested that the great Greek orator visited the seashore to
search for appropriately sized pebbles adequate to fill his palatal
defect and thereby improve his speech.
More current medical literature credits Hollerius, Petronius and
Pare with descriptions of prosthesis for obturation of palatal
defects in the 16th century.
Works by Snell, Stearn, Kingsley and Suerson in the 19th century
describes current prosthetic designs (Aramany, 1971).

DEFINITIONS
.
• A congenital split in the upper
lip on one or both sides of the
centre, often associated with a
cleft palate
CLEFT
LIP
• An opening in the hard and/or
soft palate as a result of
improper union of the
maxillary process and the
median nasal process during
the second month of
intrauterine development.
(GPT-9)
CLEFT
PALATE

EMBROLOGY
• DEVELOPMENT OF LIP
Inderbir Singh, G P Pal-Human Embryology, 9th Edition.pg-137-138

• DEVELOPMENT OF PALATE
Inderbir Singh, G P Pal-Human Embryology, 9th Edition.pg-144

RISK FACTORS
Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and
palate. The Lancet. 2009 Nov 21;374(9703):1777-79

EPIDEMIOLOGY
• Cleft Lip +/- Palate - 2 Male: 1 Female
• Cleft Palate - 2 Female: 1 Male
• Left sided clefts are more common than right sided clefts
• Unilateral clefts more common than bilateral clefts
9

Allori AC, Mulliken JB, Meara JG, Shusterman S, Marcus JR. Classification of cleft lip/palate: then and now. The Cleft Palate-
Craniofacial Journal. 2017 Mar;54(2):175-88.
DAVIS & RITCHIE CLASSIFICATION
(1922))
DAVIS &
RITCHIE
CLASSIFICATION
(1922)
Group I
Prealveolar clefts
(unilateral and
bilateral)
Group II
Postalveolar clefts
of the hard and
soft palates
Group II
Clefts of the
primary and
secondary palate

Davis JS, Ritchie HP. Classification of congenital clefts
of the lip and palate: with a suggestion for recording
these cases. Journal of the American Medical
Association. 1922 Oct 14;79(16):1323-7.

VEAU SYSTEM 1931
13
Allori AC, Mulliken JB, Meara JG, Shusterman S, Marcus JR. Classification of cleft lip/palate: then and now. The Cleft Palate-Craniofacial
Journal. 2017 Mar;54(2):175-88.

LAHSHAL SYSTEM (1985)
RIGHT LIP
RIGHT ALVEOLUS
RIGHT HARD PALATE
SOFT PALATE
LEFT HARD PALATE
LEFT ALVEOLUS
LEFT LIP
14
Rani MS, Chickmagalur NS. Classification of cleft lip and cleft palate-a review. Annals & Essences of Dentistry. 2011 Apr 1;3(2).

CLASSIFICATION ACCORDING TO GROUPS
(IOWA SYSTEM)
15
Zreaqat MH, Hassan R, Hanoun A. Cleft Lip and Palate Management from Birth to Adulthood: An Overview. Insights into Various
Aspects of Oral Health. 2017 Sep 20:100-21.

KERNAHAN’S CLASSIFICATION
16
Kernahan, d. A. (1971). The striped y—a symbolic
classification for CLEFT LIP AND PALATE. Plastic and
reconstructive surgery, 47(5), 469–470.

Kernahan, d. A. (1971). The striped y—a symbolic classification for CLEFT LIP AND PALATE. Plastic and reconstructive surgery, 47(5), 469–470.

FOGH-ANDERSEN (1946)

SCHUCHARD AND PFEIFER’S SYMBOLIC
CLASSIFICATION 1964
19

INDIAN CLASSIFICATION1975
Proposed by Dr. C. Balakrishnan
20
Agrawal K. Classification of cleft lip and palate: An Indian perspective. Journal of Cleft Lip Palate and Craniofacial Anomalies. 2014 Jul 1;1(2):78.

Agrawal K.
Classification of cleft
lip and palate: An
Indian perspective.
Journal of Cleft Lip
Palate and Craniofacial
Anomalies. 2014 Jul
1;1(2):78.

Agrawal K. Classification of cleft lip and palate: An Indian perspective. Journal of Cleft Lip Palate and Craniofacial Anomalies. 2014 Jul 1;1(2):78.

PROBLEMS ASSOCIATED WITH CLEFT LIP AND PALATE:
23
Feeding
Speech
difficulties
Esthetic
problems
Dental
Associated
anomalies
Ear
problems
Nasal
deformity
Robin NH, Baty H, Franklin J, Guyton FC, Mann J,
Woolley AL, Waite PD, Grant J. The multidisciplinary
evaluation and management of cleft lip and palate.
Southern medical journal. 2006 Oct 1;99(10):1111-21.

MANAGEMENT
Robin NH, Baty H, Franklin J, Guyton FC, Mann J, Woolley AL, Waite PD, Grant J. The multidisciplinary evaluation and management of cleft lip and
palate. Southern medical journal. 2006 Oct 1;99(10):1111-21.

GENERAL TREATMENT FOR CLEFT
PALATE
• Protruding premaxilla is shifted to a more distal
position and aids in sucking.
2 to 3 months
• cleft palate is repaired to reduce the joint
abnormalities associated with speech, eating
and drinking.
1 or 2 years
• There will be an increased discrepancy in the
size of the maxilla and the mandible, a crossed
bite, a retruded premaxilla and a shallow palate.
Early mixed
dentition stage
• no adjustments in the tooth position required
hence fixed partial denture can be provided.
20 and above
Sowmya S, Shadakshari S, Ravi MB, Ganesh S, Gujjari AK. Prosthodontic care for patients with cleft palate. Journal of Orofacial Research. 2013:22-7.

John Beumer. Maxillofacial rehabilitation
Thomas Taylor. Clinical maxillofacial prosthetics.
ROLE OF A PROSTHODONTIST
• Replacement of teeth & other missing anatomic structures
• Stabilization of the maxillary cleft segments
• Stabilization and or achieve ideal arch configuration before surgery
• Camouflage for the inadequacy in surgical or orthopaedic treatment
• To improve appearance
• To provide adequate function, including an adequate speech mechanism

INDICATIONS FOR PROSTHESIS
Failure/contradictions of surgery to the cleft palate, general health of the
individual and psychological status including motivation of the individual
Un-operated palates
Individuals with neuromuscular deficit of the soft palate and pharynx
improvement of spatial relationships with or without the orthodontic
appliance.
medical contra-indication to surgery or when a surgery is delayed then the
prosthesis can be used
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. Journal of international oral health: JIOH. 2015;7(Suppl 2):106.

CONTRAINDICATIONS
Mentally
retarded
patient.
Uncooperative
patient.
28

CRITERIA FOR SELECTION
Good oral hygiene
Acceptable occlusion
Adequate retention
Positive assessment
indications
commitment to complete
treatment.

PROSTHODONTIC MANAGEMENTLEFT
A. PROSTHESIS
IN INFANCY
PERIOD:
Feeding obturator
Presurgical naso
alveolar moulding
appliances
Palatal lift prosthesis
Speech aid or speech
bulb prosthesis
B. OBTURATOR:
Palatal obturator
with solid or hollow
bulb meatus.

C. PROSTHESIS
FOR TOOTH
REPLACEMENT:
Removable
prosthesis
Complete
dentures
prosthesis
Fixed prosthesis
Implant
prosthesis

FEEDING OBTURATOR

Neonates born with a cleft palate have difficulty in feeding, which leads to failure
to thrive
 Oro-nasal communication diminishes negative pressure, makes suckling
difficult & causes nasal regurgitation.
 Orogastric and nasogastric tubes can be effective but should be used only for a
limited length of time.
Rahul L et al.: Feeding Appliance for a 2 day old Neonate with Cleft Lip and Palate . International Journal of Oral Health and Medical Research

Advantages
1. It helps in feeding
2. Reduces nasal regurgitation
3. Prevents tongue from entering the defect
4. Allows spontaneous growth of palatal shelves
5. Contribute to speech development
6. Reduces incidence of otitis media and other
pharyngeal infections

Feeding Appliance for a 2 day old Neonate
with Cleft Lip and Palate: A Case Report
.
In the present case report, a feeding obturator was given to a 2-day old
neonate with cleft lip and palate
Lodaya R, Dave A, Kunte S, Shah R. A Feeding Appliance for a 2 day old Neonate with Cleft Lip and Palate: A Case Report. Int J
Oral Health Med Res 2017;3(6):86-89.

Primary Impression Primary Cast With Spacer
Custom Impression Tray Feeding Plate in Place
Feeding Plate

PRESURGICAL NASO ALVEOLAR MOULDING
• Described by Grayson.
• AIM Reduction in the soft tissue and
cartilaginous cleft deformity to
facilitate surgical soft tissue repair
in optimal conditions under
minimum tension to minimize scar
formation
stimulation and redirection of
growth for the controlled
predictable repositioning of the
alveolar segments and gives the
ideal arch form, normalizes the
tongue position, aids in speech
development,
improves appearance and
gives a psychosocial boost,
and improves feeding and
bone contour.
PNAM
Attiguppe PR, Karuna YM, Yavagal C, et al. Presurgical nasoalveolar molding: A boon to facilitate the surgical repair in infants with cleft lip and
palate. Contemp Clin Dent. 2016;7(4):569-573.

Objectives
To provide
symmetry to
severely
deformed nasal
cartilages
To achieve
projection of the
flattened nasal
tip
To provide
nonsurgical
elongation of the
columella
To improve the
alignment of the
alveolar ridges
and reduce the
distance between
the cleft lip
segments.

PHASES OF PNAM
• UNILATERAL DEFECT
Phase 1:
Approximation of segments
Phase 2:
Nasal cartilage moulding

• BILATERAL DEFECT
Phase 1:
Align post lateral segments & derotate
premaxilla
Phase 2:
Nasal cartilage moulding
Phase 3:
Elongation of columella

METHODS TO ACHIEVE MOULDING
42

43
1.Reduction of alveolar cleft
2.Symmetric nasal cartilages
3.Nonsurgical lengthening of
columella
4.Less surgical procedures
5.Eliminates the need of bone grafts
1.Nostril overexpansion
2.Tissue ulceration
3.Failure to retain appliance
4.Failure to tape lip segments
BENEFITS
COMPLICATIONS

Avhad R, Sar R, Tembhurne J. The Journal of prosthetic dentistry. 2014 Sep;112(3):676-9.
This clinical report describes the presurgical management of
an infant with a complete unilateral cleft of the soft palate,
hard palate, alveolar ridge, and lip.
PRESURGICAL MANAGEMENT OF UNILATERAL
CLEFT LIP AND PALATE IN A NEONATE: A
CLINICAL REPORT

By using PNAM, which acts as an adjunctive therapy, the deficient
tissues could be expanded and malpositioned structures could be
repositioned before surgical correction.

ARTICULATION DEVELOPMENT PROSTHESIS
• Repair of a cleft palate is performed by 1 year of age in
order to minimize speech articulation abnormalities
(Dorf and Curtin,1982).
• An articulation development prosthesis (Dorf et al.,
1985) is used to prosthetically create a normal palate for
speech development until the surgical repair can be
performed.
48

• This resin plate covers the gum pads and palate area but does not
extend into the cleft.
• This design permits appositional growth at the cleft margins.
• The prosthesis has a small extension into the pharyngeal area
• The prosthesis will not impede the eruption of teeth, and if any teeth
are already present, it can be designed to circumvent them.
49

PROSTHEIS
PALATAL
OBTURATOR
PALATAL
LIFT
PROSTHESIS
SPEECH
BULB
PROSTHESIS

PALATAL OBTURATOR
• A palatal obturator is a prosthetic device that can
be used to cover an open palatal defect .
• The use of a palatal obturator is appropriate if
the palatal opening is symptomatic of speech or
causes nasal regurgitation during feeding, and
surgical correction is not planned in the near
future.
• This prosthetic appliance functions by closing off
the nasal cavity from the oral cavity.
• For speech, this can normalize resonance and
improve the ability to impound intraoral
pressure for the production of speech.
51
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. Journal of international oral health: JIOH. 2015;7(Suppl 2):106.

PALATAL
OBTURATOR
INTERIM
DEFINITIVE
52

• Was first advocated by Gibbons and Bloomer.
• This type of prosthesis is specially useful for patients with
velopharyngeal incompetence.
• The objective is to displace the soft palate to the level of
normal palatal elevation, enabling closure by pharyngeal
wall action.
53
VELO PHARYNGEAL CLOSURE
PALATAL LIFT PROSTHESIS
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. Journal of international oral health: JIOH. 2015;7(Suppl 2):106.

Premkumar S. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2011 Dec ;29(6):70.
A 9-year-old female patient reported with the complaint of
hypernasality and disarticulation. Palatal lift appliance was chosen
as the treatment for correcting her speech problem.
CLINICAL APPLICATION OF PALATAL LIFT
APPLIANCE IN VELOPHARYNGEAL
INCOMPETENCE

CONCLUSION:
Palatal lift appliances are simple and efficient in reducing the
nasal air leak. Ongoing speech therapy is necessary and advised
for patients receiving palatal lift.

ADVANTAGES
• The gag response is minimized
due to the superior position and
the sustained pressure of the lift
portion of the prosthesis against
the soft palate.
• The physiology of the tongue is
not compromised due to the
superior position of the palatal
extension.
• The access to the nasopharynx for
the obturator (if necessary) is
facilitated.
• The lift portion may be developed
sequentially to aid patient
adaptation to the prosthesis.
CONTRAINDICATIONS
• If adequate retention is not
available for basic
prosthesis
• The palate is not
displaceable
• The patient is
uncooperative.

SPEECH BULB PROSTHESIS
• A speech bulb obturator, also known as a speech
aid appliance, is also a removable device that is
used for the treatment of VP insufficiency .
• When the velum is short relative to the depth of
the posterior pharyngeal wall, resulting in a VP
opening during the speech, the bulb serves to fill
in the pharyngeal space.
• The bulb sits in the nasopharynx to occlude the
VP port during the speech. This improves the
speech and can also improve swallowing because
it eliminates nasal regurgitation.
• It can also be combined with partial or complete
dentures.

REPLACEMENT OF MISSING TEETH
• Most cleft lip and palate patients will require more specialized and
continuing prosthodontic services than will noncleft patients.
• One study found that 24% of patients with cleft lip and palate were
congenitally missing premolars, compared with 6.6% in the general
population.
• Mackey et al reported that 49.6% of cleft patients had one or more
congenitally missing teeth. Also found that 21 % of patients with
cleft lip and palate had one or more supernumerary teeth.
62

Definitive prosthodontic treatment
• Definitive prosthodontic care for cleft patients is usually indicated
sometime after early adolescence, when the gamut of treatment
during the formative years has essentially been completed.
• A diagnostic wax-up and appropriate radiographs will permit both
the orthodontist and the prosthodontist to visualize the potential
esthetic arrangement, and will allow the orthodontist to make final
refinements that will enhance future prosthodontic care.
• Prior to the next consultation appointment, the clinician should
consult with the patient's other health care providers, such as the
plastic surgeon, orthodontist, and the family internist or
pediatrician. regarding their thoughts and suggestions for future
treatment
63

• When the edentulous cleft site is not closed orthodontically or
surgically, some type of prosthetic treatment is required.
• The alveolar cleft is bone grafted while the patient is in the mixed
dentition.
• This permits the eruption into the dental arch of an impacted
permanent tooth near the cleft site.
64

• Often, the initial prosthodontic care is the fabrication of a well-
fitting interim removable partial denture to replace any missing
teeth.
• This type of partial denture is especially appropriate if a bone
graft is scheduled in the future.
65

REMOVABLE PARTIAL DENTURES
• A removable partial denture is most often used but it is a temporary
form of tooth replacement.
• Although it provides good esthetics, it rest on soft tissues of the palate
and causes irritation.
• There may be movement of the prosthesis during function.
• Hence, it is used only as a definitive means of tooth replacement in
which there are multiple teeth missing and the edentulous space is too
long to be spanned by a fixed restoration and when patient cannot
afford implants

FIXED PARTIAL DENTURES
• A fixed partial denture provides a more natural tooth
replacement .
• Whenever, possible conservative, i.e. resin-bonded fixed
partial denture should be provided for anterior
replacement only.
• Alternatively, a conventional fixed partial denture can be
used
Sowmya S, Shadakshari S, Ravi MB, Ganesh S, Gujjari AK. Prosthodontic care for patients with cleft palate. Journal of Orofacial Research.
2013:22-7.

Prosthodontic Rehabilitation
Alternative of Patients with Cleft Lip
and Palate (CLP): Two Cases Report
• Ayna E, Başaran EG, Beydemir K. International journal of dentistry. 2009 Jan 1;2009.
CASE REPORT 1

Acar O, Kaya B, Saka M, Yuzugullu B. International Journal of Prosthodontics & Restorative Dentistry. 2013
Jul;3(3):120.
This case series describes prosthodontic management of cleft-lip-and-
palate patients with different cleft deformities, gender and age using
conventional prosthesis.
PROSTHODONTIC REHABILITATION OF
CLEFT LIP AND PALATE PATIENTS USING
CONVENTIONAL METHODS: A CASE SERIES

• RPDs are used only as a definitive means of tooth replacement
in which there are multiple teeth missing and the edentulous
space is too long to be spanned by a fixed restoration.
• If adequate volume of bone exists in the edentulous space,
tooth replacement can be achieved using dental implants.
• This can be placed in natural bone or at a bone-grafted site.
75

COMPLETE DENTURES
The reduced size of the cleft maxilla
Excessive inter-arch space
Lack of a bony palate
Poor alveolar ridge development and shallow
depth of the palate
Scarring from lip closure
76
Complete dentures for patients with clefts of both the primary and secondary palates are
challenging for the clinician to fabricate and for the patient to use
effectively.

FABRICATION OF COMPLETE DENTURES
Preliminary
impression
Fabrication
of a custom
tray
Border
molding
Vertical
dimension
of occlusion
Tryin
Delivery and
adjustment
77

• If an obturator is to be attached to the maxillary complete or
partial denture, it may be done at 2 different times.
• If the patient has never used an obturator, delay its fabrication
until the patient has accommodated to the denture (about 4 to
6 weeks).
• If the patient has an existing obturator, the new obturator
must be completed prior to delivery of the prosthesis.
78

• Wire loop for retention of the obturator segment is
attached with wax and checked for position at the second
try-in appointment.
• After the completed dentures are adjusted and the
occlusion is refined, the obturator is developed with
modeling plastic and fluid wax. The dentures are then
delivered at a subsequent appointment.
79

IMPLANTS
• Osseointegrated implants are of immense value for those with cleft
lip and palate, particularly edentulous or partially edentulous
patients.
• In edentulous patients they enhance stability, retention, and
support of the prosthesis to enable significant improvement of
masticatory performance.
• Recently several researches reported the efficacy of dental implant
treatment after the repair of alveolar cleft with secondary bone
grafting.
• Dental implant insertion into the reconstructed alveolus gives
functional stimulation to the grafted bone and can prevent
resorption of grafted bone

COMMON ERRORS IN THE CLINICAL
MANAGEMENT OF CONGENITAL DEFECTS
MOUTH PREPARATION:
• Teeth are to be used as abutments.
• Malposed or supernumerary teeth that may unduly
complicate prosthesis design and compromise the
maintenance of good oral hygiene should be considered,
for removal.
81

VERTICAL DIMENSION OF OCCLUSION:
• The patient with a congenital intraoral defect, especially a
complete cleft lip and palate, will seldom have an acceptable
vertical dimension of occlusion when all permanent teeth
have erupted.
• Use of simply constructed and easily adjustable temporary
restorations can assist in making this determination before
definitive procedures are undertaken.
82

PROSTHESIS CONTOURS:
• Contours of the parent prosthesis must be designed to
augment retention, stability and an esthetic appearance of
the total restoration.
83

VELAR EXTENSION DESIGN:
• The velar portion of an obturator or lift is the portion that
connects the palatal with the pharyngeal section.
• The most common form is wire or cast metal retentive loop.
• It must be of sufficient width and thickness for strength, be
passive and not create pressure on resting tissue unless
designed to do so.
84

OBTURATOR PLACEMENT:
• The most common error in obturator placement
superioinferiorly is locating it too low in the oropharynx
which interferes with tongue function.
85

 Prosthodontist is one of the member of the multidisciplinary cleft team.
 In the management of cleft lip and palate, prosthetic treatment retains an
important place.
 A Prosthodontist must be able to diagnose the defect and provide a preventive,
interventional and rehabilitative treatment to reduce the impact of the defect in
the patient quality of life.
CONCLUSION

REFERENCES
• Thomas Taylor. Clinical maxillofacial prosthetics .
• John Beumer. Maxillofacial rehabilitation
• Inderbir Singh, G P Pal-Human Embryology, 9th Edition.
• Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate. The Lancet. 2009 Nov
21;374(9703):1773-85.
• Davis JS, Ritchie HP. Classification of congenital clefts of the lip and palate: with a suggestion for
recording these cases. Journal of the American Medical Association. 1922 Oct 14;79(16):1323-7.
• Allori AC, Mulliken JB, Meara JG, Shusterman S, Marcus JR. Classification of cleft lip/palate:
then and now. The Cleft Palate-Craniofacial Journal. 2017 Mar;54(2):175-88.
• Kernahan, d. A. (1971). The striped y—a symbolic classification for CLEFT LIP AND PALATE.
Plastic and reconstructive surgery, 47(5), 469–470.
• Rani MS, Chickmagalur NS. Classification of cleft lip and cleft palate-a review. Annals & Essences
of Dentistry. 2011 Apr 1;3(2).
• Zreaqat MH, Hassan R, Hanoun A. Cleft Lip and Palate Management from Birth to Adulthood: An
Overview. Insights into Various Aspects of Oral Health. 2017 Sep 20:100-21.
87

• Robin NH, Baty H, Franklin J, Guyton FC, Mann J, Woolley AL, Waite PD,
Grant J. The multidisciplinary evaluation and management of cleft lip and
palate. Southern medical journal. 2006 Oct 1;99(10):1111-21.
• 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. Journal of international oral health: JIOH.
2015;7(Suppl 2):106.
• Lodaya R, Dave A, Kunte S, Shah R. A Feeding Appliance for a 2 day old
Neonate with Cleft Lip and Palate: A Case Report. Int J Oral Health Med
Res 2017;3(6):86-89.
• Attiguppe PR, Karuna YM, Yavagal C, et al. Presurgical nasoalveolar
molding: A boon to facilitate the surgical repair in infants with cleft lip and

Prosthodontic management of cleft lip and palate

Prosthodontic management of cleft lip and palate

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