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Management of Uncorrected Cleft Lip – an Innovative Prosthodontic Approach

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Management of Uncorrected Cleft Lip – an Innovative Prosthodontic Approach PROSTHODONTICS MANAGEMENT OF UNCORRECTED CLEFT LIP – AN INNOVATIVE PROSTHODONTIC APPROACH 1G TASNEEM RAJI 2E ESHONA PEARL 3T SREELAL 4APARNA MOHAN 5GIRI CHANDRAMOHAN ABSTRACT Instances of uncorrected cleft lip in adult or elderly patients are still seen in rural areas or among the people who are unaware of its correction in the developing countries. Adult patients who did not receive proper treatment for cleft lip are challenging for clinicians in terms of prosthetic rehabilitation especially when the patient become edentulous. This paper presents the management and personal identity revival of a completely edentulous 54 year old patient with uncorrected bilateral cleft lip. The facial deformity was characterized by irregularities of upper lip, protruded and rotated central incisors in the pre-maxillary region with multiple missing teeth in the upper jaw and completely edentulous lower jaw. Complete Dentures were inserted following extraction of the central incisors and the remaining natural teeth in the upper jaw, along with a Lip prosthesis made out of silicone that is retained to the maxillary Complete Denture by means of magnets. The patient was very pleased with the improvement in speech and chewing and she approved of her facial esthetics. The existence of uncorrected cleft in the elderly population highlights the need to improve policies in treating patients with cleft lip, mainly in developing countries. INTRODUCTION environmental factors. Some authors, argue that the cleft palate is caused by an alteration in the normal Facial clefts occur along many planes of the face fusion process. They also identify other factors such as a result of faults or defects in development or as a defect in vascular supply to the region involved, maturation of embryonic processes. These anomalies are recognized as oblique and transverse facial clefts, a mechanical alteration in tongue size, intoxication which extend from the upper lip or ala of the nose to with substances such as alcohol, drugs or toxins, and the eye and from the angle of the mouth to the ear, infections or lack of development. In contrast, some respectively. By far the most important of the facial authors attribute it to a serious defect produced by a 2 clefts is cleft lip. Usually Maxillary cleft lip can occur mutant gene, or a small defect caused by several genes. either due to failure of the globular portion of the me- Cleft Lip and palate is the most common congenital dian nasal process to unite properly with the lateral craniofacial anomaly. The increased knowledge in the nasal and maxillary process or due to a failure of the nature of the defect and of the remedial measures that mesodermal penetration and obliteration of ectodermal were helpful in allowing cleft lip and palate patients to grooves separating these mesodermal masses leads to achieve more normal participation in the community breakdown of the ectoderm causing cleft formation.1 life has attracted various specialists to aid in their The etiology is complex and depends on genetic and rehabilitation. This in turn has led to the development of different treatment philosophies. Cleft of Lip are 1 G Tasneem Raji, Final Year Post Graduate Student 2 E Eshona Pearl, Final Year Post Graduate student treated with various surgeries. Associated with these 3 T Sreelal, Professor & Head Of the Department surgical advantages there has also been a need for 4 Aparna Mohan, Senior Lecturer 5 Giri Chandramohan, Reader, Department of Prosthodontics & prosthesis since rehabilitation is not limited to anatom- Implantology, Sree Mookambika Institute of Dental Sciences, ical repair of cleft. Depending on the type and extent Kanyakumari District, Tamil Nadu, India. of cleft, several functional and morphological aspects Address for Correspondence: Dr G Tasneem Raji, 11/2 – Observatory Street, Ramavarmapuram, Nagercoil 629001. such as speech, hearing, developing of occlusion and Kanyakumari district Tamil Nadu, India. craniofacial growth may be damaged and required Email: [email protected] intervention by multidisciplinary term at appropriate Received for Publication: January 11, 2016 time for achievement of integral rehabilitation. Pros- Reviewed / Approved: January 30, 2016 Pakistan Oral & Dental Journal Vol 36, No. 1 (January-March 2016) 136 Management of uncorrected cleft lip thetic therapy, aids the patient in developing normal from the pre – maxillary region, and few teeth present speech, promoting deglutition and mastication.3 The in the right quadrant which were periodontally com- prevalence of cleft lip and palate among the general promised and had lower jaw with a bilateral cleft in population depends on racial, ethnic and geographic the upper lip, which had not been previously corrected. origin, as well as on socio-economic status. It has been The in eating, difficulty during mastication and speech estimated to range from 1:500 to 1:2500 live births. (Fig 2). The patient was referred to the Department Cleft lip occurs in 20-30% of cases, cleft lip and palate of Oral and Maxillofacial surgery for extraction of in 35-50% and cleft palate alone in 30-45%.2 the remaining natural teeth that were periodontally Prosthetic treatment allows patients feel more nor- compromised. The treatment plan was discussed and mal, increases their self – esteem and offers them with explained to the patient. The patient had a collapsed greater opportunities for employment and for fulfilling Vertical Dimension, following total extraction (Fig 3). their social potential.3 Various prosthetic choices are The treatment plan was to fabricate a conventional max- available for cleft patients with the development of illary and mandibular complete Denture, characterized osseointegrated implants, and the number of treatment to match the patient’s complexion and a Lip prosthesis options have further increased. The combination of bone made out of RTV silicone that is to be retained to the grafting and implant — supported fixed or removable maxillary complete Denture, by means of Magnets. prostheses represents an invasive treatment approach Primary impressions were made with addition sil- whereas, a conventional fixed or removable prosthesis icone (Aquasil, Dentsply, Germany) for Maxillary and represents a more conservative alternative for patients Mandibular jaw in order to record the cleft that extends who refuse surgical intervention.4 Lip Prosthesis: The to the upper lip from the maxillary arch (Fig 4). The aim of a facial prosthesis is to fulfill the esthetic needs undercut areas present in the nasal region were blocked of the patient and to improve the patient's quality of life. with gauze pieces which were dipped in saline. Topical It is important that the patient be informed regarding anesthetic gel was applied on the undercut regions to the esthetics outcome. The rehabilitation of maxillary reduce the discomfort level of the patient. Primary lip defects is a significant challenge in terms of creat- or Diagnostic casts were poured with dental plaster ing retention. The advent of magnets has enhanced (Neelkanth Minecham, Rajasthan, India.) and special the dental practitioner's capabilities in this regard trays were made for maxillary and mandibular arch with a remarkably improved potential for increasing with autopolymerising resin (DPI company, Mumbai, prosthesis stability and preserving tissue. Extra oral India). Border moulding was done with green stick or defects producing gross anatomical changes produces low fusing compound (DPI company, Mumbai, India) deformity and affects the body image of the individ- and secondary impression was made with monophase ual. Creating facial prostheses to restore mid facial silicone impression material (Aquail, Dentsply, Germa- defects involves many challenges. Apart from making ny) (Fig 5) Master cast was poured with Dental stone the patient socially vulnerable the lip defect prevents (Neelkanth Minecham, Rajasthan, India.) following adequate speech and deglutition. The speech problems beading and boxing of the border molded maxillary are mainly associated with bilabial and labiodental and mandibular special trays. The master casts were phonemes. With lack or compromised oral competency, duplicated with alginate and heat cure denture base leading to drying and crusting of the tissues in the area was fabricated for maxillary and mandibular arch, with of the defect. The goals of prosthodontic treatment is to heat activated acrylic resin (DPI company, Mumbai, restore appearance and function.4 Prosthesis is espe- India.) Maxillo-mandibular relationship was recorded cially useful in case of lost body parts, as reconstructive following construction of occlusal rims using modelling surgery cannot fully restore aesthetics. Various mate- wax (Modelling wax No. 2, The Hindusthan dental rials such as wood, clay, leather, enameled porcelain, Products, Hyderabad, India) over the denture bases and acrylic resin and silicone elastomers are used in and were articulated in the mean value articular (Fig the fabrication of extra oral prosthesis. Among these, 6). Teeth selection (Acryrock Teeth set, Italy) was acrylic resin and silicone are the most commonly used done, based on patient’s facial form, shape and shade. materials for rehabilitation. Maxillofacial prostheses Anterior and posterior wax trial were done in the fol- require frequent replacement because the elastomers lowing appointments (Fig 7 & Fig 8). After carving and and its coloring agents undergo changes. Silicones can polishing, final wax up was done in
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