Cleft lip and palate

Restoration of Cleft Lip and Palate

Arun Sharma DDS
Department of Preventive and Restorative Dentistry, UCSF
John Beumer III, DDS, MS
Ting Ling Chang, DDS
Division of Advanced Prosthodontics, UCLA
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Table of Contents
v  Facial and palatal development
v  Classification of clefts
v  Incidence
v  Etiology
v  Early intervention and counseling
v  Lip repair
v  Palatal repair
v  Growth and development and orthodontic
treatment
v  Arch expansion eruption of teeth
v  Cuspid substitution

Table of Contents
v  Adjunctive surgical procedures
v  Orthognathic surgery
v  Pharyngeal flap
v  Nasal revision
v  Role of obturator prosthesis in children
v  Closing oronasal fistulas and grafting the cleft
v  Stabilizing non-grafted cleft segments
v  Replacing the missing lateral incisor
v  Complete dentures
v  Role of osseointegrated implants
v  Zygomaticus implants for clefts
v  Overlay removable partial dentures
v  Role of osseointegrated implants

Development of Facial Structures

Drawings depicting the formation of the face from the frontal
perspective from the fourth week through the eighth week.
From Patten, B. M., 1969

Cleft lip and palate
Diagnosis
v Prenatal Ultrasound

Cleft

Development of Facial Structures

A.  Median nasal process
B.  Lateral nasal process
C.  Maxillary process

Palatal Development
" Palatogenesis begins 5th week
" Completed by the 12th week

Develops from two primordia:
The primary palate
The secondary palates

Development of the Palate

Section of the head of the embryo
late in the eighth week

Palatal Development

Graphic summary of palatal fusion
from the 6th week to the 9th week.

Classification of Clefts
v  Cleft lip and alveolus (primary palate)
v  Cleft of the hard and soft palate (secondary palate)
v  Combinations of these two

v  Clefts can be bilateral or unilateral
v  Embryologically, anterior clefts differ from posterior clefts

Classification of Clefts
Cleft patients may also present with other
abnormalities
" Syndromic forms (15%)
" Nonsyndromic forms (85%)

Possible combinations of Cleft Lip and Palate

Incidence of Clefting

" 1 in 700 infants born
" Left sided clefts account
for 70%

Highest rates in American Indians (1 in 278
births) followed by the Japanese, Maoris,
Chinese, Caucasians and African Americans
(1 in 3,330 births).

Incidence

Cleft lip (with or without cleft palate)
" One in every 1000 births
" Males affected twice as frequently as
females

Incidence
Cleft Palate (with or without Cleft Lip)
" With or without cleft lip, occurs once in 2500 births
" Isolated clefts of the palate are more common in females*

*May be due to the
fact that the palatine
processes fuse
about 1 week later
in females than in
males.

Etiology
v Geneticfactors
v Environmental factors affecting the
mother during the first trimester
v Infection
v Hormonal imbalances
v Poor diet
v Teratogenic agents*

*Ethanol, folate antagonists, alkylating agents, phenytoin, trimethadione,
valproic acid, benzodiazepines, meprobamate, barbiturates

Treatment Sequence
Lip repair
Palatal repair
Orthodontic treatment
Secondary surgical procedures
Pharyngeal flaps
Bone grafting the cleft
Repairing the nasal deformity
Orthognathic surgery
Replacing the missing dentition

Early Intervention and Counseling
" Cleft team members assist with the emotional
and social adjustment of the family
" Before leaving the hospital parents should be
able to feed the infant and examine and clean the
cleft

Feeding
A variety of feeding aids have been developed to
aid in feeding the cleft infant.

Genetic Evaluation
v Parental history
v Exposure to teratogens

v Family history
v Relativeswith a cleft, lip pits, mental
retardation, congenital heart disease,
limb and ocular disorders

v Syndromic
conditions
v Chromosomal analysis

Team Evaluation
Teams are usually comprised of an audiologist,
geneticist, genetic counselor, nurse
coordinator, oral and maxillofacial surgeon,
orthodontist, otolaryngologist, pediatrician,
pedodontist, plastic surgeon, prosthodontist,
speech pathologist, and social worker.

Role of Prosthodontist
v  Nasoalveolar molding
v  Interim obturators/speech aids
v  Management of edentulous spaces
v  Tx planning restorations for missing teeth and
correction of tooth size discrepancies
v  Unrepaired cleft palates

Current protocol
for most major cleft palate teams
Early counseling –prenatal/feeding
Taping or naso-alveolar molding (NAM)
Lip repair
Palate repair
Speech therapy
Pharyngeal flap
Orthodontics
Alveolar cleft graft
Orthognathic surgery
Replacing missing teeth
Lip and nose revision

Presurgical Infant Orthopedic Appliance
(PSIO)
l  McNeil 1950, Mylin 1968, Latham 1980
l  To move the alveolar segments closer
together

Nasoalveolar Molding Appliance
(NAM)
v  Reduce the size of the intraoral alveolar cleft
v  Mold and position the surrounding soft
tissues including the deformed soft tissue
and cartilage in the cleft nose.
v  Tissue expansion - Columella

Nasoalveolar Molding Protocol
(Grayson et al, 2001)

Early intervention <1m
Labor intensive 1-2hrs/wk x 12-24wks
Bilateral cleft Need 5-6mths molding
Unilateral cleft Need 3mths molding

v  Alveolar or nasoalveolar molding from birth to 12 wks
v  12-14 wks primary cleft lip repair, nasal, and GPP
(gingivoperiosteoplasty) in one stage

Nasoalveolar Molding Appliance
(NAM)
Result
Ø  Overall improvement in the esthetics of the
naso-labial complex – Less scarring
Ø  Minimize the extent of surgery and the overall
number of surgical procedures

Nasoalveolar Molding Appliance (NAM)
Impressions and casts

a b c

a. During impression, infant’s head must in an upright
position and well supported. b. Impression of silicone
putty. c. Master cast.

Fabrication of the oral portion of NAM appliance

l  Cast made from the master cast-wax blockout.
l  Oral portion of PNAM device made of clear acrylic resin.
l  Completed device on altered cast. Note posterior
extension. Excessive length in this area will precipitate
gagging.

Clear acrylic resin

Fill the cleft region of the palate and alveolus to
approximate the contour & topography of an intact
arch


l  Diagrammatic representation of the
subtractions and additions made to NAM
device in unilateral cleft.


v  Fill
in cleft with wax
v  Restore palatal contours
v  Duplicate cast

v  All tissue border must be smooth
v  Proper contour and finish for tongue space
v  Limit posterior extension to avoid gagging

Unilateral clefts
Oral molding portion plus nasal extension

How to retain the oral
Adhesive tape
molding appliance?
&
elastics

Unilateral clefts

v The nasal extension serves as a custom tissue expander to
correct the flattening nasal deformity It also brings the
columella into a more midline position.
v Adjustments and additions are performed weekly
v  Note the molding of the nasal cartilage. This projection is
formed chair side with temporary denture reline materials

Unilateral clefts

v  Nasoalveolar molding is nearly complete. The columella is
approaching midline and the nostril on the cleft side is becoming
more symmetrical.
v  It usually takes 4-6 weeks to attain proper alignment of the alveolar
cleft segments. At 3 months most patients are ready for surgery

Bilateral clefts

v  In addition to realigning cleft segments a principle advantage of NAM
in bilateral clefts is elongation of the columella for this often eliminates
the need for further surgery to elongate this structure.
v  NAM of bilateral clefts consists of three stages
v  Repositioning the posterior palatal segments and rotating the premaxilla
into position
v  Repositioning the alar cartilages
v  Lengthening the columella

Bilateral clefts

v  Nasoalveolar molding device for bilateral cleft. Nasal
extensions in position.
v  In bilateral clefts, when the premaxilla attains a
reasonable position, nasal molding begins. The tips of
the nasal extension should be kept close together.
Otherwise the tip of the nose and the columella will be
excessively widened.

Bilateral clefts

v  As the position and contours of the nose and nasal cartilages
become more normal, elongation of the columella begins. A
horizontal strip of soft acrylic resin, the so-called prolabial band, is
secured to the two nasal extensions. The prolabial band cinches
the columella and provides length rather than width to the
columella.
v  This method, when effectively employed, will lengthen the
columella by 4-7 mm.

Bilateral clefts

Avoid excessive pressure at the lip columella
junction. Doing so may result in ulceration of
this area, compromising the final result.

Before and after NAM

The patient is now ready for surgery. It
usually takes 5-6 months before the tissues
are optimized and the patient is ready for
surgery.

For details see: Brecht L. “Nasoalveolar Molding” in Maxillofacial
Rehabilitation: Prosthodontic and Surgical Management of Cancer-related,
Acquired and Congenital Defects of the Head and Neck. Eds. Beumer J,
Marunick M, Esposito S. Quintessence Pub Co. Chicago, IL, 2011 pp 324-9

Surgical Treatment – Lip Repair
Rule of tens:
Lip is repaired* when the patient is 10
weeks old, 10 pounds in weight, with a
hemoglobin count of 10.

*The first surgery is usually performed
at about 3 months. This period may be
extended to complete NAM, particularly
in patients with bilateral clefts.

A B C

Modified Le Mesurier surgical technique for lip closure.
A: Development of flaps. B: Flaps prepared for
closure. C: Lip closure.
*Methods of closure were developed based on the nature of the
cleft, the deficiency of the tissues associated with the cleft, and
consequences of scar contracture.

Unilateral cleft

After lip repair. Note the nasal asymetry. The scarring from
the closure of the lip and cleft will impair the development of
normal nasal contours and will probably require correction in
the future.

Bilateral cleft

After lip repair. Note the short columella. The scarring from
the closure of the lip and cleft will impair the development of
normal nasal contours and will require correction in the future.

Complications associated with
lip repair
v  Multiple additional
surgeries
v  Less than ideal
esthetic result
v  Notethe excessive
scarring associated
with this lip closure
of a bilateral cleft

Surgical Treatment – Palatal Repair
Timing – Approximately 10 months
Methods of closure vary
depending upon:
v  Extent of the cleft
v  Availability
of tissue
v  Experience of the surgical team

Palatal pushback procedure

Surgical Treatment – Palatal Repair
Timing of closure is a matter of opinion. Two
positions:
"   Delayed closure (Zurich approach) – Less inhibition of
maxillary growth
"   Early closure – Better speech patterns develop early

Palatal push back and closure procedure

Complications associated with
palatal repair
v  Shortsoft palate
resulting in
velopharyngeal
insufficiency.
Speech will be
hypernasal.

Growth and Development
Growth may be inhibited by:
v  Intrinsictissue deficiencies
v  Quality, amount and location of scar tissue secondary to
the surgical repairs

Growth during primary and mixed
dentition stage

Complicating factors
1. Tight lip
2. Scar tissue bands in the palate
These phenomenon result in a deficiency in the
downward and forward growth of the maxilla
because of impaired alveolar development.

Orthodontic treatment – Purposes:
v Expand the maxilla to correct segment position and crossbite
v Monitor eruption of teeth

Treatment begins during the mixed dentition stage.

Orthodontic treatment

Patient with a repaired unilateral cleft.
Note the arch expansion after one year.
It is vitally important that the maxillary fragments not be allowed to collapse
medially. If they do the tongue will rest on the dentition preventing further
development of the maxilla and impair alveolar development.

Orthodontic treatment – Other considerations
"   Should the missing lateral incisor space be kept open for
prosthetic replacement with an implant supported restoration or
closed by eruption and medial movement of the cuspid.

Choice depends upon:
"   Size and shape of the cuspid and the size of the maxilla.
"   If it is decided that the cuspid should come forward, the cleft is grafted after
arch expansion but before the cuspid has moved down into the bony defect.

Orthodontic treatment – Other considerations
"   Should the missing lateral incisor space be kept open for
prosthetic replacement with an implant supported restoration or
closed by medial eruption and movement of the cuspid.

v Bilateral clefts we favor canine substitution.
v Unilateral clefts we tend to create space orthodontically
for placement of an implant

Growth and development during
adolescence
v  Progressive retrusiveness of the maxilla may
occur during later growth.
v  The tight lip scar and scar tissue bands in the
palate impede the forward growth of the maxilla as
well as the alveolar processes

Adjunctive Surgical procedures
Orthognathic Surgery

As a result many cleft patient require a maxillary
osteotomy to bring the maxilla down and forward.

Pharyngeal Flaps
v Mostvelopharyngeal discrepancies for cleft patients are
managed surgically, usually with a combination of a palatal
push back and closure procedure (9-18 months).
v However in a small percentage of patients, a superiorly based
pharyngeal flap (3-7 years) is required to enable the patient to
achieve velopharyngeal closure.

Superiorly based pharyngeal flap.

Pharyngeal Flaps
v  Flaps are raised on the nasal surface of soft palate and
from the pharyngeal wall. The pharyngeal flap is rotated
onto the soft palate as shown.
v  As organization and contracture occurs, the soft palate is
pulled toward the area of normal closure.


Pharyngeal Flaps
" Closure of the lateral portals is accomplished by contracture
of lateral pharyngeal walls.
" Today only a small percentage of patients require flaps


Correcting nasal deformities

Objectives
"  Lengthen the columella
"  Correct deficiencies
associated with the
nasal cartilage on the
cleft side
"  Develop proper contours of
the nasal tip

Correcting nasal deformities
Objectives
"  Lengthen the columella
"  Correct deficiencies
associated with the
nasal cartilage on the
cleft side
"  Develop proper contours of
the nasal tip

This patient has a rather typical
result after nasal revision surgery

Correcting lip deficiencies
Contour deficiency often occur secondary to scarring
associated with closure. Note the corrections made
in the length of the lip, the lip line and contour.

Correcting lip deficiencies
Contour and tissue deficiencies occasionally occur
secondary to scarring associated with closure

Lip switch (Abbey flap)
"  In this procedure a pedicle flap from the lower lip is used
to provide more tissue for the upper lip.

Lip switch (Abbey flap)

A typical result. Note the scar on the lower lip

Role of Obturator Prosthesis in Children
v  Clefts of the secondary palate with a paucity of
residual palatal tissues
v  Poor anesthetic risks
v  Failed pharyngeal flaps

Very short soft palates following surgical repair

The repaired soft palate is quite short in both of these
patients and cannot reach and engage the posterior
pharyngeal wall during velopharyngeal closure. As a result
speech will be hypernasal and swallowing will be impaired.

Failed pharyngeal flap. Why has it failed to restore
speech?

The pharyngeal flap is too low to effectively interact with
the lateral pharyngeal walls during velopharyngeal
closure. As a result speech is hypernasal.

Interim Speech Aids
Soft palate obturators are fabricated in the usual fashion
(see “Restoration of Soft Palate Defects” FFOFR.org)

v  Fabricate palatal stent with adequate retention.
v  Gradually develop the pharyngeal extension.
v  When the child is has accommodated to the pharyngeal
extension, develop the obturator portion.

Interim Speech Aids
The bulb is molded with compound and
thermoplastic wax.

v The extensions of the prosthesis are
developed with dental compound and a
thermoplastic wax
v Following processing the contours
and extensions are verified with
pressure indicating paste and/or
disclosing wax (see “Restoration of soft
palate defects” FFOFR.org for details).

Interim Speech Aids
A completed speech bulb

Obturator prostheses restore velopharyngeal function very
effectively and are well tolerated by the patient. They need
to be remade periodically to account for growth and eruption
of the permanent dentition.

Obturator prosthesis
for failed pharyngeal flaps

Obturators for failed
pharyngeal flaps are rarely
successful because it is
difficult to extend the
prosthesis superiorly to
engage the movable lateral
pharyngeal walls.

Obturator prosthesis
for failed pharyngeal flaps
In this patient, the bulb resulted in constant contact with non-
mobile pharyngeal tissues, resulting in hyponasal speech.
The bulb was discarded and the flap removed.

Velopharyngeal function and
normal speech was eventually
restored with a new obturator
prosthesis after the flap had
been removed.

Stabilizing the cleft
segments after orthodontic treatment
Following orthodontic care
rapid relapse and arch
collapse occurs if the clefts
are not rigidly secured.
This relapse is primarily
due to the stretching of the
midline scar secondary to
surgical closure of the cleft.

Since the 1950’s two methods have been used:
v  Fixed partial dentures (1950 – mid 1970’s)
v  Autogenous bone grafts (mid 1970’s – present)

Bone Grafting the Cleft
Goals for grafting the cleft
v  To separate the oral and nasal cavities
v  To stabilize the maxillary segments with a bony union
v  To provide normal quality of bone in the alveolus for
orthodontic movement and support of teeth
v  To provide adequate 3 dimensional bone volume for
placement of osseointegrated implants

Bone Grafting the Cleft
Timing of grafting
v  Mixed dentition stage is preferred by most
teams
v  Early grafting (during infancy) of the cleft
may have a negative affect on the growth
of the maxilla

Closing oronasal
fistulas and grafting the cleft

Graft material

Nasal mucosa lining as
well as oral mucosal lining
is required to enclose the
graft material.

Stabilizing non-grafted cleft segments
Fixed partial dentures – From the 50’s thru the mid 70’s the maxillary
fragments were often stabilized with fixed partial dentures.

Full veneer crowns were
required to maximize retention.
Two abutments or more in each
cleft segment is recommended.

Fixed partial dentures – From the 50’s thru the mid 70’s
the maxillary fragments were often stabilized with fixed
partial dentures.

In this patient partial veneer crowns were sufficient.
Two abutments were used in each cleft segment.

Fixed partial dentures – From the 50’s thru the mid 70’s
the maxillary fragments were often stabilized with fixed partial
dentures.

In this patient partial veneer crowns were sufficient.
Double abutments were used in each cleft segment.

Restoring the missing and malformed dentition
Dental discrepancies of patients with clefts

v  Missing lateral incisors (40%)
v  Maxillary central adjacent to the cleft
is often undersized
v  Teeth in the premaxilla have
shortened roots
v  24% have missing premolars
v  More likely to possess super-
nummery teeth (21%)
v  Teeth adjacent to cleft often present
with hypocalcified enamel
v  Hypodontia (50%)

Replacing the Missing Lateral Incisor
Implants - Issues
" Growth - Skeletal Development
"  Dental alveolar
"  Mandible and maxilla
"  It is advisable to wait until two consecutive cephalometric
films one year apart show no evidence of growth
" Site development
"  Horizontal and vertical deficiencies usually present

Cuspid substitution vs implants

v Bilateral clefts we favor canine substitution.
v Unilateral clefts we tend to create space orthodontically
for placement of an implant

Replacing the missing lateral incisor
Removable Partial Dentures

A rotational path of insertion
RPD was used to replace
the lateral incisor.

Implants
Issues
"  Consequences of premature
placement
"  Implant will be submerged
relative to the adjacent teeth
with the attendant esthetic
consequences
"  Less favorable implant
biomechanics ie. crown root
ratios

In this patient with a missing lateral incisor, the implant was placed prior to the
completion of growth. As the adjacent natural dentition continued to erupt and
the implant crown appeared submerged relative to the adjacent teeth.

Implants
Issues
"  Consequences of premature
placement
"  Implant will be submerged
relative to the adjacent teeth
with the attendant esthetic
consequences
"  Less favorable implant
biomechanics ie. crown root
ratios

See “Implants in Growing Children” FFOFR.org for details

Implants

At age 21 the implant crown
was replaced. Note the
discrepancies associated
with the the gingival levels
of the lateral incisors.

Implants - Issues
v Gingival contours are not quite normal
Why?
Scarring associated with the closure and grafting the
cleft

Consequences: None. Almost all cleft patients have a low smile line.

Note gingival contours.
These are to be expected given
the scarring secondary to the
multiple surgical procedures
necessary to close and graft the
cleft.

UCSF Data (Sharma and Vargervik, 2006)

"   24 patients (15 male, 9 "   33 implants placed
female) "   31 implants restored
"   9 bilateral clefts "   28 still in function
"   15 unilateral clefts

Grafting the Cleft and Placing Implants
Average age in years (UCSF data)

"  Alveolar cleft bone graft - 14.3
"  Range (12 – 26) Median 15

"  Implant Placement - 18.1
"  Range (14 – 28) Median 19

Most clefts present with either horizontal or vertical
bone deficiencies and require grafting prior to
implant placement

Implant Placement n = 33

"  Adequate bone
15 (45.4%)
"   Need for regraft
18 (54.6%)

Results
v Implants placed - 33
v  Implants restored - 31
v  Implants in function - 28

*2 implants failed at 2nd stage
*2 failed in a bilateral cleft after 4 years
*1 failed in a unilateral cleft after 11 years

Follow up Time (months)

"  Time since placement - 133.6 mths
(Range 85 – 166. Median 130)
"  Time since restored - 129 mths
(Range 74 – 158, Median 121)

Complete Dentures
Treatment concepts – Challenges and Difficulties
"   The reduced size of the denture foundation
area
"   Excessive interarch space
"   Lack of a bony palate
"   Poor alveolar development with shallow
depth of the palate
"   Scarring from lip closure
"   Scarring in the posterior palatal seal area
"   Presence of oro-nasal fistulas
"   Opposing natural dentition
"   Misaligned and extruded teeth
"   Soft palate defect

All these factors negatively impact the retention, stability and
support provided the complete denture.

Complete Dentures

In these three patients note:
"   Reduced size of denture
foundation area
"   Large oronasal fistulas
"   Little or no alveolar ridges
"   Soft palate defect

Complete Dentures

In these two patients note:
v  Scarring in the posterior palatal seal area
v  Collapsed maxillary arch segments

Complete Dentures
Treatment concepts – Challenges and
Difficulties
Result:
v Dramatically compromised stability,
retention and support
v Bilateral balance is virtually impossible
to obtain if the opposing arch is dentate

Most patients cannot masticate effectively with
these dentures. The primary benefits are improved
lip contours and esthetics, speech articulation and
swallowing without nasal leakage.

Complete Dentures
Making Impressions
Border mold with low fusing compound
v Posterior palatal seal - single bead
v Avoid excessive tissue displacement in heavily
scarred areas
v Develop the labial flange to support the lip

Corrected impression
v  Carefully examine for small fistulae
v  Block out fistulae before making corrected impression
v Use a polysulfide wash impression material
v  This material is less likely to fracture and become
imbedded in undetected fistulae

Complete Dentures
Vertical Dimension of Occlusion
v  Normal in patients with reasonable
development of the alveolar processes
v  Interocclusal space is increased in patients
with very small maxilla and little alveolar
ridge height
v  Since most patients present with a severe
Class III jaw relationship the posterior teeth
are set in crossbite and the anterior teeth
arranged in an edge to edge relationship

Complete Dentures
Try in appointment
Esthetics
Anterior tooth display should be harmonious
with lip thickness, scarring and contours.
For example:
A protruding lip scar can be made less
conspicuous by moving the lateral incisor
palatally.

Making repeatable centric relation records.
In patients with a very deficient maxilla it is
advisable to use processed record bases.

The oral surfaces of the soft palate obturator
extension must be concave

This complete denture was made for a patient with a partially
repaired cleft lip and palate. Note that the anterior flange is
much thicker than normal. Note the concave oral surface of
the obturator extension to the posterior pharyngeal wall. Flat
or convex oral surfaces may cause gagging or difficulty during
swallowing

Role of Osseointegrated Implants

Without the retention and stability provided by
implants mastication performance is
significantly degraded in edentulous patients
with cleft lip and palate fitted with complete
dentures. Retention and stability are
particularly compromised when the prosthesis
extends into the velopharyngeal region.

The addition of implants can have a dramatic impact on patient function and
their placement should be given serious consideration in all such patients.

Role of Osseointegrated Implants  
Patient presents with a repaired bilateral cleft of
the lip and palate 
Note:
v  The premaxillary
segment is
missing
v  The cleft has not
been
reconstructed with
a bone graft
v  The profound
Class III jaw
relation


v Implants have been placed into each of the remaining posterior
palatal segments and into the anterior region of the mandible.
v The remaining posterior palatal segments move independent of
one another during occlusal function and therefore it is best not to
connect one side to the other with and implant connecting bar.

Implant connecting bar designs

Note:
v  The implant connecting bar does not cross the cleft
v  The bars are designed as an anterior extension
v  When occlusal loads are applied anteriorly, the prosthesis rotates
around the Hader attachments. The ERA attachments permits the
prosthesis to be impacted into the anterior denture foundation areas.

Implant connecting bar designs

Both designs are considered implant assisted designs
v  In the maxilla implant support is provided posteriorly but the
anterior forces are born by the edentulous denture foundation
areas available for coverage and engagement.
v  In the mandible implant support is provide anteriorly by the
implant connecting bar but posterior support is provided by the
primary support areas of the mandible-the retromolar pad and
the buccal shelf.


Completed prosthesis. Note:
v  Crossbite
v  The upper lip has been
reconstructed with an Abbey
flap.


v Implants were placed bilaterally
v The two implants on the left failed.
v Implant connecting bar was
designed to provide retention
and stability but they are not
the primary means of support.

Zygomaticus implants for clefts

Advantages vs sinus augmentation
v  Fewer surgeries
v  Reduced treatment time
v  No donor site morbidity


Issues to consider during
treatment planning
v  Generally two implants are placed on
each side.
v  The implants are then splinted
together with an implant connecting
bar


v  The implants are splinted together with an implant
supported connecting bar
v  An removable partial denture supported anteriorly
by implants and posteriorly by the remaining
molars


l  An overlay RPD was fabricated
for the maxilla and an overlay
complete denture for the
mandible
l  Note the lip support provided by
the prosthesis

a b c

d e f g

a: Edentulous patient with repaired bilateral cleft.
b,c: Four implants have been placed, two conventional and two
zygomaticus types.
d: Implant supported implant connecting.
e: Prosthesis.
f: Prosthesis in place. Note obturator extension. g: Final result.

Overlay Removable Partial Dentures
Usual clinical findings
v  Collapsed maxillary arches
v  Inadequate alveolar development
v  Excessive inter-occlusal space
v  Retarded growth of the maxilla

Purpose of the prosthesis
" Restore the missing dentition
" Restore the vertical dimension of occlusion
" Provide support and contour for the upper lip

Purpose
" Restore the missing dentition
" Restore the vertical dimension of
occlusion
" Provide support and contour for the upper
lip. Note the thickness and contour
of the labial flange


Important note:
" Before making preliminary or master impressions
carefully inspect the repaired cleft for fistulas. These
areas must be carefully blocked out with gauze prior to
making impressions in order to prevent impacting
impression materials within the nasal cavity.


" If the interocclusal distance is excessive and the VDO
overclosed, an improved vertical dimension of occlusion can
be established with selective crown placement

Copings on premolars to These copings will be enclosed
be overlayed protect within the overdenture.
these teeth from caries.

Crown contours are
made ideal for the partial
overdenture framework.

Note the thickness of
the labial flange.
The processed overdenture
with the border molded soft
palate obturator.

These copings are
incorporated within the
overlay denture.


Note:
l  Anterior open bite
l  Fistulas
l  Soft palate defect


v  Remaining teeth covered with gold copings.
v  Tooth tissue junction should be covered with metal as
opposed to acrylic resin
v  Implants placed in posterior quadrant.

Border molding the soft palate portion

The obturator portion is developed with compound and thermoplastic
wax. (see “Restoration of soft palate defects” FFOFR.org for details).

Design of the metal framework

" Note that the tooth tissue junction of all overlaid teeth are covered with
metal as opposed to acrylic resin. The resin is porous and if you cover
these areas with this material you will increase the risk of gingival caries
" Note the metal occlusal surfaces overlaying the implant connecting bar.
This was done to accommodate for the lack of space between the
implant connecting bar and the opposing natural dentition.

Definitive prosthesis.

The premaxilla of this patient
has been removed. Note the
fistula anteriorly. This must
be carefully occluded with
gauze before making
impressions. The maxillary
molars were restored with full
veneer crowns to restore the
VDO to a proper level.

The premolars were covered with copings and splinted to
the first molars. The prosthesis will overlay these copings.
Note the ERA attachments (arrows). These attachments
retain the prosthesis but disengage when incisal forces
are delivered. The axis of rotation is determined by the
distal rests on the first molars bilaterally (arrows).


This cleft was not bone grafted and therefore the
individual segments move independent of one another
exposed to the forces of mastication. Therefore cleft
segments have not been united prosthodontically.


The prosthesis inserted. Circumferential clasps
have been used. Note the anterior overlay.


The anterior overlay restores the anterior dentition,
provides lip support and obturates the anterior
fistula.


Implants can provide cleft patients significant benefit particularly those
restored with an overlay prosthesis. This patient has retained only the
maxillary 2nd molars. The removable partial denture she was wearing
restored the missing dentition and provided support for the lip but lacked
anterior support. Implants provided the needed support.


A lateral cephalogram indicated sufficient bone available
anteriorly and implants were place on both sides of the
cleft. Note that the premaxilla had been removed
previously.


A “Hader bar” and an “O” ring type attachment were
use to retain the overlay prosthesis.

The occlusal surfaces of the
mandibular teeth were altered to
alleviate occlusal plane
discrepancies.


The finished prosthesis in position. The posterior mandibular
dentition was restored with a removable partial denture. The
cleft segments had not been grafted together an so they
were not splinted with the implant apparatus.

Obturating residual soft palate
defects not previously obturated
" Speech will remain hypernasal but leakage during
swallowing will be reduced.
" Long standing errors in
articulation remain.

v  Visitffofr.org for hundreds of additional lectures
on Complete Dentures, Implant Dentistry,
Removable Partial Dentures, Esthetic Dentistry
and Maxillofacial Prosthetics.
v  The lectures are free.
v  Our objective is to create the best and most
comprehensive online programs of instruction in
Prosthodontics

Cleft lip and palate

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