Opening New Horizons and Creating a Normal, Functional Life for Cleft Palate Patients By Tanja Geurtse In partial fulfilment of BTech: Den Tech. Degree September 2004

Content Patient historyPatient history Condition and backgroundCondition and background Possible treatment optionsPossible treatment options Treatment option most suitableTreatment option most suitable Treatment option of choiceTreatment option of choice Laboratory proceduresLaboratory procedures ReferencesReferences

History  1996 Consultation at Tygerberg Hospital  26 year old female  Cleft palate  Severe Class 3 bite  Severe occlusal abnormalities  Unknown syndrome  Poor oral hygiene  Difficult at chair side  Appliances break

 Le fort 1 Osteotomy  Correct occlusal abnormalities  Followed up with halo frame (8 weeks)  Followed up with an orthodontic device  Maintains occlusion (2 months)  Acrylic resin interim obturator 5 Condition and Background Condition and Background

Condition and Background cont.  Bilateral saggital split  Genioplasty  Acrylic mandibular removable partial denture

Possible Treatment Options Possible Treatment Options Maxilla: Maxilla:  Acrylic Pharyngeal obturator  Cobalt chromium Pharyngeal obturator Mandible:  Implant supported crowns  Acrylic Removable partial denture  Cobalt chromium removable partial denture

Cobalt chromium Pharyngeal Obturator Cobalt chromium Pharyngeal Obturator Advantages:  Acts as speech aid  Palatopharyngeal closure  Prevents nasal leakage  Enhances breathing  Enhances swallowing  Very strong 6

Cobalt chromium Pharyngeal Obturator cont. Cobalt chromium Pharyngeal Obturator cont. Disadvantages:  Large obturator weight  Stress on abutment teeth  Lack of posterior teeth, compromises success 7  Difficult to adjust  Requires long, parallel guide planes on abutment teeth for retention and stability  More difficult to fabricate 6

Acrylic Pharyngeal Obturator Advantages: Advantages:  Improves palatopharyngeal incompetence  Acts as speech aid  Improves speech disorders  Enhances swallowing  Enhances normal breathing  Prevents nasal leakage  Easy to adjust  Easier to fabricate than cobalt chromium R.P.D 6

Acrylic Pharyngeal Obturator cont. Disadvantages: Disadvantages:  Not a panacea for hypernasal speech  Discomfortable and bulky  Too heavy  Dislodgement  Acrylic not strong in thinner areas  Clasp arms bend easy  Clasp arms can be annealed mechanically  Loss in flexibility  Reduced strength 6

Implant Supported Crowns Advantages: Advantages:  Improves aesthetics  Less pressure on frontal plate  Stable  Durable 6

Implant Supported Crowns cont. Disadvantages:  Requires patient responsibility  Possible failure  Operation required  Higher cost than previous options (R 6200)

Acrylic Removable Partial Denture Advantages:  Easy: -to clean and maintain -repair and adjust  Not as expensive as implants (R1 200)  Simple to design and fabricate

Acrylic Removable Partial Denture cont. Disadvantages:  Acrylic not strong in thin areas  Too bulky  Not stable  Dislodge  Clasp arms bend easy  Clasp arms can be annealed mechanically  Loss in flexibility  Implants have better aesthetics

Cobalt Chromium Removable Partial Denture Advantages:  Very strong  Less bulky  Easy to clean  Doesn’t impinge on tongue space

Cobalt Chromium Removable Partial Denture cont. Disadvantages:  May bruise bulky tissue  More difficult to fabricate  Small appliance  Can be swallowed easily

Treatment option most suitable Acrylic Pharyngeal Obturator Reasons for choice:  Improves palatopharyngeal incompetence  Acts as speech aid  Improves speech disorders  Enhances swallowing  Enhances normal breathing  Prevents nasal leakage  Easy to adjust  Easier to fabricate than cobalt chromium R.P.D 6

Treatment option most suitable and of choice Mandible Mandible Chrome Cobalt Removable Partial Denture Chrome Cobalt Removable Partial Denture Reasons for choice:  Very strong  Less bulky  Easy to clean  Doesn’t impinge on tongue space

Treatment Option of Choice Maxilla Cobalt chromium Pharyngeal Obturator Cobalt chromium Pharyngeal Obturator Reasons for choice:  Stronger than acrylic obturator  Improves palatopharyngeal incompetence  Enhances swallowing  Enhances normal breathing  Increased retention, support and stability  Light in weight 6

Laboratory Procedures  Receive impressions  Pour primary models  Special tray  Pour secondary models  Duplicate model (Agar)

Laboratory Procedures cont.  Wax up maxillary obturator:  Full palatal major connector  Two clasps with rests on the 2.4&1.7  Roach clasp with rest on the 1.3  Saddle areas for acrylic teeth  Extension to close the cleft

Laboratory Procedures cont.  Invest wax pattern  Cast framework  Metal framework divested, trimmed and finished  Wax up with acrylic teeth  Try in  Invested  Packed with acrylic  Cured  Divested, trimmed and finished

Laboratory Procedures cont.

 Severe undercuts  Wax up mandibular obturator:  Lingual bar becomes labial and buccal bar  Buccal bracing arms  Lingual retentive arms  Ackers clasp and rests -Extended to 4.5 and 4.6  Ackers clasp and rests -Extended to 3.6 and 3.7  Eliminates accidental swallowing

Laboratory Procedures cont.  Invest wax pattern  Cast framework  Metal framework divested, trimmed and finished  Wax up with acrylic teeth  Try in  Invested  Packed in heat cured acrylic  Cured  Divested, trimmed and finished

References 1.Booth P W, Eppley B L, Schmelzeisen R. Maxillofacial Trauma and Aesthetic Facial Reconstruction. London:Churchill Livinstone. 2003: Booth P W, Eppley B L, Schmelzeisen R. Maxillofacial Trauma and Aesthetic Facial Reconstruction. London:Churchill Livinstone. 2003: Branemark P, Tolman D E. Osteointergration in Craniofacial Reconstruction. London: Quintessence Publishing Co, Inc. 1998: Kernahan D A, Rosenstein S W. Cleft Lip and Palate: A System of Management. London: Williams & Wilkins. 1990: Taylor TD. Clinical Maxillofacial Prosthetics. London: Quintessence Publishing Co, Inc. 2000: Taylor TD. Clinical Maxillofacial Prosthetics. London: Quintessence Publishing Co, Inc. 2000: