Role of prosthodontist in cleft rehabilitation

1. Dr PRATHIBHA PRASAD
Postgraduate
Dept of Prosthodontics
KCDS
CLEFT LIP AND PALATE
REHABILITATION

2. INTRODUCTION
• The cleft lip and palate deformity is a congenital defect of the middle third of
the face, consisting of fissures of the upper lip or palate
• It is the second most common congenital anomaly after clubfoot
• Amoung the 15 types of orofacial clefting, cleft lip and palate is the most
common one.
• It may be congenital (i.e. born with disability) or may acquired (as a result of
carcinoma spreading from the maxillary antrum).

3. • Treatment is unique in that it begins at birth and is usually not competed until
the end of second decade.
• Multi-disciplinary management with interaction among the various
specialists of the cleft palate team is essential in order to achieve optimum
results.

4. HISTORY
• Hippocrates (400 BC) and Galen (150 AD) mention cleft lip, but not cleft
palate in their writings
• Cleft palate – Fanco (1556)
• Repair of cleft lip – as early as 255-206 BC in China- An 18-year-old
youth, Wey Young-Chi was operated successfully
• The first successful closure of a soft palate defect was reported in 1764
by LeMonnier, a French dentist
• In INDIA - Tribhuvandas Motichand Shah in Junagadh, who performed
reconstructions of mutilated noses using the median forehead flap in the
19th century.

5. • In ancient times, many congenital deformities, including the cleft lip and palate,
were considered to be evidence of the presence of an evil spirit in the affected
child.
• In Sparta, the unfortunate newborns were abandoned on Mount Taget.
• in Rome they were drowned in the Tiber River or thrown off the Tarpeian rock.
• In the ancient Mediterranean civilizations these children were said to possess
supernatural powers.

6. INCIDENCE

7. • Worldwide one in 600 (1:600)
• A child is born with a cleft somewhere in the world every 2 minutes
according to a WHO study published in 2001
• 37% are born with an isolated cleft lip,
• 63% are born with cleft lip and palate.
• 70% occur as isolated anomalies
• 30% occur in association with other congenital anomalies and
recognized syndromes

8. • More common clefts are –
• Unilateral clefts
• Males female ratio is 2:1
• Left sided (twice)
• Males more affected by cleft lip
• Females more affected by cleft palate
• 10-30% of cases are associated with skin bridges called Simonart’s bands

9. EMBROYOLOGY
• occurs between the 4th and 12th weeks of intrauterine life, period during which
the embryonic development of the face and palate are taking place.
• 5 facial prominences around stomatodeum
1. Unpaired frontonasal process
2. Paired maxillary prominences
3. Paired mandibular prominences

10. In following 2 weeks after 4th week
• The 2 medial nasal processes fuse in midline – upper lip
• Mandibular processes fuse in midline – lower lip

11. • The maxillary and lateral nasal process separated by nasolacrimal
• groove/duct
• • Frontonasal process – bridge of the nose
• • Medial nasal process – tip of nose and philtrum of upper lip
• • Lateral nasal process – ala of the nose

12. Palate development
Formed from
• The two palatal processes
• The primitive palate formed from frontonasal peocess

13. • Secondary palate – formed from 2 outgrowths from maxillary prominences –
palatine shelves
• Fuse in midline at 7th week
• Incisive foramen – midline landmark between primary and secondary palate

14. FORMATION OF CLEFTS
• Failure of fusion of maxillary and medial nasal processes – anterior to
incisive foramen
• Failure of fusion of palatine shelves – posterior to incisive foramen
• Cleft lip – failure of fusion of one or both maxillary processes with medial
nasal process

17. ETIOLOGY
GENETICS
ENVIRONMENTAL
MULTIFACTORIAL

18. GENETICS
• The etiopathogenic mechanism is related to a pattern of multifactorial
inheritance, which requires the interaction between genetic and
environmental factors, interfering with the molecular signalization and
expression.
• Nearly 3 to 14 genes may be involved in the determination of cleft lip and
palate. TGFA JAG2
TGFB2 LHX8
TGFB3 SATB2
FGF SKI
FOXE1 ERBB2
GLI2 SPRY2
TBX10 MSX2
MSX1 IRF6

19. • It is estimated that participation of the gene
• MSX1 in the occurrence of clefts is nearly 2%
• Participation of gene FGF is 5%
• 12% for the gene IRF6

20. • Chances increases if more than one family member is affected
• More the severity, greater the chances of recurrence in sibling
• Higher risk if affected individual is of less affected sex
• Risk decreases in remotely related individuals
• Consanguinity increases the rate because of sharing of genes

21. ENVIRONMENTAL
• Nutritional deficiency (vitamin, proteins, folic acid)
• Hormonal imbalance (diabetes Mellitus, hyper-thyroidism, hypothyroidism,
• Drugs and chemicals (Antimetabolites, tetracyclines, sulfonamides, quinine)
• Physical injuries (pressure, temperature change, radiation)
• Maternal diseases ,infections
• Teratogens like: Rubella virus, Cortisone/ steroids, Mercaptopurine,
Methotrexate, Valium, Dilantin

23. OTHER FACTORS
• Age
• Emotional disturbances, stress
• Multiple pregnancies
• Alcohol and smoke

24. CLASSIFICATION
I. DAVIS AND RITCHIE (1922)
• Based on the location of the cleft with respect to the alveolar process
• Group I - Pre alveolar cleft :
Unilateral
Bilateral
Median.
• Group II - Post alveolar cleft : with involvement of soft and hard palate
• Group III - Alveolar cleft :
Unilateral
Bilateral
Median

25. VEAU AND RECAMIER CLASSIFICATION (1938)
• Based on morphological involvement
• Group 1 - Cleft of soft palate
• Group 2 – Cleft of soft and hard palate up to incisive foramen
• Group 3 – Complete unilateral cleft of soft palate, hard palate, alveolar ridge and
lip
• Group 4 – Complete bilateral cleft of soft palate, hard palate, alveolar ridge and
lip

26. ANDERSON CLASSIFICATION (1942)
• Based on embryological involvement
• Group 1 - Hare lip
• Single
• Double
• Group 2 - Hare lip and cleft palate
• Single
• Double
• Group 3 - Cleft palate

27. KERNAHAN AND STARK’S CLASSIFICATION

28. AMERICAN CLEFT PALATE–CRANIOFACIAL ASSOCIATION
(ACPA) CLASSIFICATION (1962)
• Clefts of the prepalate (cleft of lip and embryologic primary palate)
a. Cleft lip (cheiloschisis)
b. Cleft alveolus (alveoloschisis)
c. Cleft lip, alveolus, and primary palate (cheiloalveoloschisis)
• Clefts of the palate (cleft of the embryologic secondary palate)
a. Cleft of the hard palate (uranoschisis)
b. Cleft of the soft palate (staphyloschisis or veloschisis)
c. Cleft of the hard and soft palate (uranostaphyloschisis)

29. • Clefts of the prepalate and palate (alveolocheilopalatoschisis)
• Facial clefts other than prepalatal and palatal
a. Cleft of the mandibular process
b. Naso-ocular clefts
c. Oro-ocular clefts
d. Oroaural clefts

30. DIAGNOSIS
• Prenatal ultrasound – 2D or 3D
• Prenatal counselling
• 22% to 33% rates for detecting facial clefts
• Color Doppler ultrasonography can also be used

31. ULTRASOUND TECHNIQUE
• Non-invasive diagnostic tool
• Confirm fetal viability
• Determine gestational age
• Establish number of fetuses and their growth
• Check placental location
• Examine fetal anatomy for detecting malformations

32. Transabdominal US
- Not reliable till gestational age of 15 weeks
- Done at 20 or more weeks of gestation
Transvaginal USG
- Earlier visualization (12 weeks)
- Better image resolution
- Greater specificity and sensitivity

33. Babcock and McGahan (1997)
- Starts with coronal plane
- Assessment continues in axial view
- Bilateral clefts: sagittal view
- Isolated clefts: axial view

34. ADVANTAGES OF PRENATAL CLEFT
DIAGNOSIS
• Psychological preparation for parents to have realistic expectations
• Parent education for cleft management
• Preparation for neonatal care and feeding
• Opportunity to investigate other abnormalities
• Possibility of fetal surgery

35. DISADVANTAGES OF PRENATAL CLEFT DIAGNOSIS
• Emotional disturbance
• High maternal anxiety and dysfunction
• Termination of pregnancy

36. LIMITATIONS OF ULTRASOUND TECHNIQUE FOR DIAGNOSING
OROFACIAL CLEFT INCLUDE:
• Unfavorable position of fetus
• Hand or umbilicus overlying the face
• Maternal obesity
• Presence of multiple gestation
• Reduced amniotic fluid
• Prior abdominal surgery
• Additional fetal abnormalities

37. PROBLEMS ASSOCIATED WITH CLEFT
LIP AND PALATE

38. DENTAL
SKELETAL
NASAL
FEEDING
EAR PROBLEMS
SPEECH
ASSOCIATED ANOMALIES

39. DENTAL
• Tooth agenesis, hypodontia (most common)
• Supernumerary teeth (2nd most common)
• Enamel hypoplasia (CI)
• Crossbites
• Ectopic eruption, transposition
• Taurodontism, dilacerations

40. SKELETAL
• Maxillary deficiency
• Mandibular prognathism
• Class III malocclusion
• Concave profile

41. FEEDING PROBLEMS
• If both the hard and soft palates are cleft the natural process of
swallowing is impossible and the first problem facing those nursing a
child born with a cleft palate is concerned with its feeding.
• In spite of the problems which faces the infant with a cleft palate, in
most cases it adapts itself to spoon feeding and sometimes to suckling
if the head is turned on one side so that the milk may be swallowed
between the tongue and the side of the palate.

42. • In the case of a very extensive cleft, however, this is impossible and
it may be necessary to construct an acrylic plate to enable the child to
swallow.

43. SPEECH
• The initial sound of speech is produced in the larynx and travels as a
vibrating airstreams either through the mouth where it is modulated into
articulate sounds by the tongue, palate, lips and teeth, or through the nose
where the nasal cavities and associated sinuses produce a nasal resonance’s.
TYPES OF SOUNDS
• B and P sounds (labials)
• T and D sounds (lingo-dentals)
• G and K sounds (lingo-palatals)
• Fricatives ( s, z ,f and c sounds)
• Nasal consonants (m, n and ng sounds)

44. • The production of all oral sounds requires the airstreams to be under
some degree of pressure and this can only be maintained and correctly
directed through the cavities of the mouth if the soft palate and
pharyngeal walls are producing an airtight seal to nasal escape.
• In the individual with a cleft palate, this is not possible and the
airstream escapes through the nose.

45. • to prevent this the back of the tongue is thrust into the cleft and if the
treatment of the cleft either by surgical or prosthetic means is delayed
much after the second year this tongue habit becomes well established
and even after treatment has been given makes correct speech
difficult

46. SYNDROMES ASSOCIATED
WITH CLEFT LIP & PALATE
• Around 400 syndromes
Chromosomal anomalies
• Trisomy 13 (Patau)
• Trisomy 18 (Edward)
• Trisomy 21 (Down’s)
• Velocardiofacial syndrome (22q11 deletion)

47. Inherited syndrome
• Sticklers (Autosomal dominant)
• Treacher Collins (AD)
• Van der Woude (AD)
Non-inherited syndrome
• Pierre Robin Syndrome – triad of cleft palate, glossoptosis, retrognathia
• Goldenhar syndrome
Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994

48. Teratogenic
• Fetal alcohol syndrome
• Fetal phenytoin syndrome
• Fetal valproate syndrome

50. HISTORY
• Alexander Pare in 1564 - obturators for
both cleft and syphilitic defects.
• Pierre Fauchard Surgeon – dentist in 1728
was still using obturators.
• 1766 a French dentist Lee Marnier
reported the first successful palate repair
using hot cautery and horse hair suture.

51. • 1850-1890 include Dietenback’s lateral relaxing incisions,
• Bill Roth’s modification at the tensor veli palatine muscles,
• Lang Han-back’s fracture at the hamular process to release the tensor
tendon.
• In 1943, Dr.Harkim (dentist) and Dr.Baker (speech pathologist)
established a multi disciplinary “Cleft Palate Team”

53. OBJECTIVES
• Restoration of masticatory apparatus
• Aesthetic( facial and dental)
• Socially acceptable speech
• Psychological adjustment to the patient and the family.

54. Pediatrician – Responsible for overall
general health of the infant, adequate
nutrition and hydration, monitor the
development of the child
Nurse – Take care of special nursing
consideration during feeding,
examine and clean the cleft and teach
the parent about child care
Surgeon – Surgical reconstruction of
cleft lip and palate
Pedodontist – maintenance of dentition
during early stage ;
establishment of good oral hygiene

55. Orthodontist – Manage pre-surgical orthopedic
treatment,improve
alignment of teeth and stimulate growth of arch
orthodontically;
standard orthodontic therapy in permanent dentition
Otolaryngologist – Manages any condition occurring in
nose, throat and ear
Audiologist / Speech therapist – Evaluation of speech
therapy for
refinement of speech production
Prosthodontist – The role of prosthodontist in cleft palate
team can begin with the fabrication of neonatal prosthesis or
nasoalveolar moulding prosthesis on some special cases

56. Social Worker / Psychologist –
Provide supportive care for the
parents, monitors intellectuality and
emotional development
Genetic counselor – Genetic
evaluation of all medical records for
family members; counseling with
parents concerning the etiology,
incidence and risk to future
offsprings

57. TREATMENT PROTOCOL
• AT BIRTH
• Prosthodontist/Pedodontist may construct feeding plate and initiate
presurgical dental orthopedics.
• Team member are introduced to the parents and emphasize the need for
adequate weight gain so child can attain necessary stage of development
before lip surgery.
3 MONTHS
• Surgical repair of lip; bilateral cleft lip cases may be repaired as a two stage
procedure

58. • 6 months
• Preventive dentistry begins
• 15 – 18 months
• surgical repair of palate, speech therapist assesses

59. • 2 Years
• plastic surgeon reviews surgical results.
• Orthodontist examines teeth and soft tissues especially noting
relationships of anterior segments and depths of labial sulcus in cleft
region.
• ENT surgeon assesses hearing and examines tympanic membrane,
• speech therapist continues to monitor speech.
• Pedodontist stresses importance of good dental health.
• 3 years
• – Dental check up at 4 month intervals, other team members review
progress anually

60. • 4 years –
• ENT surgeon usually performs audiography and compliance
tests, and if necessary places grommet woes in ear drums,
• speech therapy starts for children with speech and hearing
problems.
• 7 years
• - Early correction of malalignment of anterior teeth and
labial segment relationship
• 9 Years
• – surgical lip and nose revision to improve appearance.

61. • 12 years
• Orthodontist corrects malocclusion and treats crowding and
malalignments.
• Expansion of maxillary arch may be necessary. Teeth may be moved
so as to create space for bone graft or for fixed or removable
prosthesis
• 16 years
• Plastic surgery to improve the appearance of the nose.
• The oral surgeon may perform a Le Fort 1 part 1 maxillary osteotomy
to correct retrusive appearing maxilla,
• replacement of missing teeth with fixed bridge or removable
prosthesis

62. 16 years on wards
• Prosthodontist and restorative dentist provide regular routine dental
care

63. NASOALVEOALAR MOULDING
• Grayson (1999) adapted his nasal stent to extend from the anterior flange of an
intraoral molding plate.
• This new technique was named – “ Nasoalveolar molding”
• The nasoalveolar moulding appliance (NAM) consists of an intraoral moulding
plate with nasal stents to mould the alveolar ridge and nasal cartilage
concurrently
Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.

64. OBJECTIVES
• Reduce severity of initial cleft deformity
• Columella – Nonsurgical lengthening (in bilateral clefts) and uprighting (in
unilateral clefts)
• Reduction in the width of the alveolar cleft segments until passive contact of
the gingival tissues is achieved.
• significantly improve the surgical outcome of the primary repair in cleft lip
and palate patients compared to other techniques of presurgical orthopaedics.

65. PROCEDURE
• A heavy-bodied impression material is used to take the
initial impression as soon after birth as possible
• The infant is held upside down by the surgeon and the
impression tray is inserted into the oral cavity.
• The infant is held in an inverted position to prevent the
tongue from falling back and to allow fluids to drain out
of the oral cavity.
• The tray is seated until the impression material
adequately covers the anatomy of the upper gum pads.
• .
. Indian journal of plastic surgery: official publication of the Association of
Plastic Surgeons of India. 2009 Oct;42(Suppl):S56.

66. • Once the impression material is set, the tray is
removed, and the mouth is examined for residual
impression material

67. • The moulding plate is fabricated on the
dental stone model
• A retention button is fabricated and
positioned anteriorly at an angle of 45° to the
plate
• In the unilateral cleft only one retention arm
is used
• The retention button adequately secures the
moulding plate in the mouth with the help of
orthodontic elastics and tapes
• A small opening measuring 6–8 mm in
diameter is made on the palatal surface of the
moulding plate to provide an airway in the
event that the plate drops down posteriorly.

69. retention arm positioned approximately
40° down from the horizontal to achieve
proper activation and to prevent
unseating of the appliance from the
palate. Note that there is no nasal stent
placed for the first few weeks of
treatment

71. • The nasal stent component of the NAM appliance is incorporated when the width
of the alveolar gap is reduced to about 6 mm. The rationale for delaying the
addition of the nasal stent is that as the alveolar gap is reduced, the base of the
nose and the lip segment alignment is also improved
• The stent is made up of 0.36 inch, round stainless steel wire and takes the shape
of a ‘Swan Neck’.

74. COMPLICATIONS
• Irritation of the oral mucosal or gingival tissue
• Ulceration of intraoral tissues
• The intranasal lining of the nasal tip can become inflamed
• Skin irritation due to tape usage
• Parent compliance required
• Moulding plate may get dislodged and obstruct the airway

75. CLEFT LIP REPAIR
• Goal: improve facial aesthetics by restoring nasal and lip contour
• Timing: 3 to 6 months
• •Millards “RULE OF TEN”
[term coined by Wilhelmmesen and Musgrave in 1969]
• 10 weeks (age)
• 10 pounds (weight)
• 10 gm/dl (Hb)

76. • Techniques:
• Tennison – Randall (Z-Plasty)
• Millards rotation advancement repair
• Rose – Thompson straight line repair

77. CLEFT PALATE REPAIR
• Von Langenback
• V-Y palatoplasty by Veau
• Furlow’s technique
• Wardill Kilner’s push back

78. BONE GRAFTING FOR ALVEOLAR CLEFT
DEFECTS
BONE
GRAFTING
Primary
bone
grafting
First 2 years of
life
Secondary
bone
grafting
Early – 2 to 5
years of life
Late – 11 to 14
years of life
Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod

79. OBJECTIVES FOR SURGICAL GRAFTING
• Stabilization of segments
• Improved oral hygiene
• Nasal secretions prevented from draining into the mouth
• Unites maxilla to better withstand occlusal forces
• Bony base for teeth eruption
• Improves nasal symmetry
• Provide feeling of normalcy and improve social acceptance

80. SURGICAL MANAGEMENT OF ALVEOLAR CLEFT
• Ideal timing:
- 9 to 11 years of age
- Before canine eruption, canine root is 1/3rd formed (Bergland et al)
• Best source of bone graft: (autologous cancellous bone)
- Anterior portion of iliac crest
- The rib, tibia
- The cranium
- The mandible

82. • Earlier surgical and orthodontic intervention for most patients has
resulted in less complex problems in the teen and adult years.
• As a consequence of better results achieved through earlier treatment,
the role of the prosthodontist in the team has changed somewhat in
recent years

83. National journal of maxillofacial surgery. 2010 Jan;1(1):91.

85. • This article presents a case report of an adult male patient with surgically repaired
cleft lip and unrepaired palate, rehabilitated by a combination of FDP with an
extracoronal attachment retained gingival veneer and a cast partial hollow-bulb
obturator
• A 25-year-old male patient with a surgically treated unilateral cleft lip and
unrepaired unilateral complete cleft of the primary and secondary palate on the
left side was referred to the Department of Prosthodontics, for prosthetic
rehabilitation.

86. facial asymmetry, repaired unilateral cleft
lip on the left side with distinct atrophic
scar contracting the upper lip,
concave profile, retruded upper lip, the
reduced thickness of the vermillion part of
the upper lip, prominent lower lip, and
positive lip step
4 cm × 4 cm residual palatal defect
extending rightward to the alveolar ridge
and hyperplastic soft tissue surrounding
the hard palate defect.
large oronasal communication, leading to
nasal reflux of food and water and
distorted articulation

87. • it was decided to rehabilitate the maxillary anterior segment with an
FDP and an extracoronal attachment retained gingival veneer.
• The residual palatal defect was to be restored with cast partial
hollow-bulb obturator prosthesis.
• After thorough clinical and radiographic analysis, it was decided to
choose both central incisors, both canines and right lateral incisor as
abutments. Intentional endodontic treatment was done for all the
abutment teeth as they were rotated and for the long-term prognosis
of the prosthesis

91. PROSTHETIC SPEECH APPLIANCE

93. Palatal Lift Prostheses For The Treatment Of Patients Requiring
Velar Elevation, Velopharyngeal Stimulation, And Velopharyngeal
Obturation
• two prosthodontic procedures are available to
us in the treatment of patients with
velopharyngeal inadequacies:
1. Lift type
2. Combination of lift and bulb
• The lift type of prosthesis is used to elevate
the soft palate to the maximum position
attained during normal speech and deglutition

94. • The combined lift/bulb prosthesis should be the method of choice when the soft
palate is insufficient for the proper velopharyngeal closure. The combined
lift/bulb prosthesis is used to elevate the soft palate,obturate the gap, and
stimulate velopharyngeal development and pharyngeal constriction

95. RESTORATION OF DENTITION:
• Prosthodontic care during preadolescent year is limited but definitive
treatment is indicated after early adolescences. If there are missing,
mal posed or unaesthetic anterior teeth, the initial prosthodontic care
is the fabrication of a well fitting removable partial denture for
esthetic purpose.

96. The Journal of prosthetic dentistry. 2019 Jan 1;121(1):9-12.

99. implant-supported milled gold
bar assemblies with terminal
friction fit attachments
titanium reinforced complete
upper overdenture.
A 35-year-old woman with a repaired left complete cleft of the lip and palate
who had been rendered edentulous in the maxilla secondary to rampant caries
during orthodontic treatment as a teenager

100. Atlas of the oral and maxillofacial surgery clinics
of North America. 2008 Mar 1;16(1):61-82.

101. • This article presents the prosthodontic rehabilitation of a congenitally
bilateral cleft lip and palate patient with a unique method which
fulfilled the patient’s needs, esthetics and psychological well being.
• This is a case report of a patient aged 52 years who reported to the
department of Prosthodontics with the complaint of missing anterior
teeth.
• On examination it was found that this was a case of congenital
palatopharyngeal malformation of the palatal insufficiency category
coupled with bilateral cleft lip
The Journal of Indian Prosthodontic Society.
2010 Dec 1;10(4):253-6

102. • The patient had not consulted any specialist before for any kind of
rehabilitative procedures and over the years had got adapted to live
with his defect.
• On positive reinforcement he consented for the treatment plan for an
acrylic Hollow bulb obturator replacing the missing teeth with
bilabial prosthetic attachments.

103. • problem was encountered in retaining the left side lip prostheses as
there was no edentulous space present similar to the right side defect.

104. • The right lip prostheses was planned to be attached with the replaced
11 and 12. So a special loop shaped retainer standing 5 mm away
from the teeth, passing between 22 and 23 was specially designed for
holding the left lip prostheses

105. • Wax up for the lip prosthesis was
done at this stage over the labial plate
(right) and wire loop (left side).
• It was contoured in an arc shape as
the middle lobe was short and high
and was static during function

108. RECENT ADVANCES
• Fetal surgery – done in intrauterine life (prior to 20 weeks)
• Non-life threatening defects like cleft lip, cleft palate, Pierre Robin
syndrome, Treacher-Collins syndrome, craniofacial microsomia
• Open fetal surgery
• Feto-endoscopic approach

109. ADVANTAGES
• Provide a scarless repair, “ripple effect” is eliminated
• Correct the primary deformity,
• Prevent secondary deformities, and
• Give the parents a "normal“ - appearing child at birth
Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J
Plast Surg. 2005 Jul;58(5):593-607

110. CONCLUSION
• Oral clefts are the second most common congenital anamoly, having
multifactorial origin A considerable knowledge about the etiology and
embryology is required for proper diagnosis and treatment planning of such
patients . Treatment begins soon after birth and continues till adulthood
requiring a team approach. The decision for prosthetic rehabilitation is made
based on the individual patient needs, motivation for improvement and
availability of the suggested rehabilitative program. Approximate 50% of all
patients with cleft lip and palate will need some type of fixed or removable
prosthesis by 30 years of age and is managed by we prosthodontists

111. REFERENCES
• Agarwal A, Rana V, Shafi S. A feeding appliance for a newborn baby with cleft lip and
palate. National journal of maxillofacial surgery. 2010 Jan;1(1):91.
• Lorenz HP, Longaker MT. In utero surgery for cleft lip/palate: minimizing the “Ripple
Effect” of scarring. Journal of Craniofacial Surgery. 2003 Jul 1;14(4):504-11.
• Geethu RM, Anilkumar S. Esthetic and Functional Rehabilitation of an Adult Cleft
Lip and Palate Patient Using Combined Fixed and Removable Prosthesis. Journal of
Interdisciplinary Dentistry. 2018 Jan 1;8(1):35.

112. • Berkowitz S, editor. Cleft lip and palate: diagnosis and management. Springer
Science & Business Media; 2006 May 20.
• Pucciarelli MG, Lopes AC, Lopes JF, Soares S. Implant placement for
patients with cleft lip and palate: A clinical report and guidelines for
treatment. The Journal of prosthetic dentistry. 2019 Jan 1;121(1):9-12.
• Taylor TD, editor. Clinical maxillofacial prosthetics. Berlin; 2000.
• Chalian VA, Drane JB, Standish SM. Maxillofacial prosthetics:
multidisciplinary practice. Baltimore, USA: Williams & Wilkins Company;
1972.

113. • Thomas S, Mohan AS, Rupesh PL. Hybrid maxillofacial prosthesis: A case report.
The Journal of Indian Prosthodontic Society. 2010 Dec 1;10(4):253-6.