Prosthetic treatment of closed vertical dimension in the cleft palate patient

PROSTHETIC TREATMENT OF CLOSED VERTICAL IN THE CLEFT PALATE PATIENT

DIMENSION

MOHAMMAD MAZAHERI, D.D.S., M.Sc.*

Lancaster, Pa.

of occlusion and lack of maxillomandibular occlusal contact in the cleft palate patient can be related to the following abnormalities: (1) partial eruption of the deciduous and permanent teeth, (2) failure of normal vertical and late,ral growth and development of the maxillae, (3) generalized disturbances of the growth pattern resulting from the cleft palate anomaly, (4) displacement or damage to the tooth bud and supporting bone during surgical procedure on the palate, (5) subsequent scar tissue formation and disturbance of blood supply to the tissue, and (6) impacted, supernumerary, malposed,and ankylosed teeth.

0

VERCLOSURE OF THE VERTICAL DIMENSION

DESCRIPTION OF THE PROBLEM

Lack of lateral and vertical growth of the maxillae and partial eruption of the deciduous and Ijermanent teeth are often seen in patients with congenital cleft palate. These p&ients frequently have congenitally missing, impacted, badly decalcified, or decayed maxillary teeth (Fig. 1). The maxillary arch is often constricted. Maxillary and mandibular teeth do not contact when the mandible is in *Chief, Dental Services, Lancaster Cleft Palate Clinic.

Fig. l.- An l&year-old girl has a postoperative unilateral cleft lip and cleft palate. Some scar tissue remains in the hard and soft palate. Cineradiography studies indicate that velopharyngeal closure is present. The remaining maxillary teeth are decalcified, partially erupted, and decayed. 187

MAZAHERl

Fig. 2.-The

maxillary and mandibular teeth do not contact when the patient’s mouth is closed in centric occlusion. Note the excessive lateral growth of the tongue.

Fig. 3.-The

upper left central

incisor and upper right supernumerary gingivectomy has been performed.

Fig. 4.-The

copings are cemented in position.

tooth are removed

and a

i%!:E: ‘1’

CLOSED

VERTICAL

DIMENSION

WITH

CLEFT

189

PALATE

centric occlusion (Fig. 2). The upper and lower teeth are widely separated when the mandible is at physiologic rest position. The gingival sulcus is deepened because of partially erupted teeth.

Fig.

5.-The

tissue

surface

of the prosthesis. The cast gold thimbles by the lateral extensions on the casting.

Fig. CLINICAL

f3.-The

denture

are

held

in the

resin

base

ls completed.

EVALUATION

In cleft palate a most satisfactory We have treated a natural teeth. This

patients, a prosthesis that is supported by natural teeth achieves result with less damaging effects upon the supporting tissues. number of patients with complete dentures constructed over the type of prosthesis not only diminishes the occlusal load upon the

J. Pros. Den. Jan.-Feb., 1961

MAZAHERI

190

mucoperiosteum and supporting bone but also has a splinting effect upon the remaining teeth. The results are encouraging, and the periodic posttreatment examinations have shown little or no tissue changes.

Fig. 7.-The

mouth is closed in centric occlusion with the prosthesis

in position.

TREATMENT

Gingivectomy is often indicated to expose more clinical crown (Fig. 3). After the complete recuperation of the gingival tissue, all remaining teeth are prepared to receive copings. Shoulderless preparations are used. The multiple impression technique is employed. Because of the excessive amount of interocclusal distance the jaw relations are not established at this stage.

Fig. 8 Fig. S.-The Fig. S.-The

prosthesis prosthesis

Fig. 9

is not in the mouth. is in position in the mouth.

The abutments are waxed, and the wax patterns are surveyed for the path of insertion and undercuts. The patterns are made parallel and all the undercuts are removed. The wax patterns are cast, and the copings are cemented into position (Fig. 4).

i%t%z ‘1’

CLOSED

VERTICAL

DIMENSION

WITH

CLEFT

PALATE

191

A preliminary impression is made, and an acrylic resin tray is made over the preliminary cast using one sheet of wax for relief. The resin tray is tried in the mouth and adjusted. Adapt01 is used for border modification. The maxillary tissue and teeth are cleaned of saliva, and the final impression is made in a rubber-base impression material. The impression is boxed and poured in artificial stone. An occlusion rim is made over the resin base. The vertical dimension of occlusion and centric relation are established in the same manner as if the patient were completely edentulous. The master cast is duplicated and the abutments are covered with 16 gauge wax. The wax patterns extend 5 mm. laterally beyond the gingival margins around the abutments (Fig. 5) for fixation of the thimbles to the resin base of the denture. The wax patterns are invested and cast in hard gold. The inner surfaces of the thimbles are well polished. The artificial teeth are arranged over the thimbles. After approval of the try-in, the denture is flasked and the wax is boiled out. The thimbles are cemented to the abutments of the cast to prevent the seepage of acrylic resin into the thimbles during packing of the denture. The denture is processed in the usual manner, polished, and inserted in the mouth (Figs. 6 through 9). When a speech bulb is indicated, the patient must be completely adjusted to the anterior part of the restoration before the “tailpiece” is added to the denture. The impression for the speech bulb is made after the patient has become accustomed to the tailpiece. We do not insist on obtaining an accurate impression for the preliminary speech bulb. An accurate impression is made after the patient’s pharyngeal tissue has become accustomed to the temporary speech bulb. The tailpiece and the preliminary bulb are constructed from self-curing acrylic resin. The tailpiece and speech bulb are not cured with heat-curing resin until an accurate impression for the speech bulb is made.r SUMMARY

Lack of lateral and vertical growth of the maxillae and overclosure of vertical dimension are often seen in cleft palate patients. Complete dentures supported by natural teeth are the ideal treatment for these patients. Copings of the remaining teeth are made to prevent decalcification and caries. The abutments are utilized only to support the prosthesis, not for retention. The prosthetic speech restoration is constructed in three stages, each stage requiring a functional impression. An accurate functional impression of the speech bulb is obtained after the patient has adjusted to the temporary speech bulb. Heat curing of the restoration should be minimized. REFEREN,CE

1. Cooper, H. K.. Long, R. E., Cooper, J. A., Mazaheri, M., and Millard, R. T.: Psychological, Orthodontic, and Prosthetic Approaches in Rehabilitation of Cleft Palate Patient, D. Clin. N. America, pp. 381-393, 1960. LANCASTER CLEFT PALATE CLINIC 24-26 NORTH LIME ST. LANCASTER, PA.