Denture Challenges in a Patient with Cleft Lip and Palate
by Nicholas Miller, DMD, MS, FACP, Board Certified Prosthodontist | Georgia Prosthodontics
A 41 year old female patient presented to the clinic with a congenital unilateral left cleft lip and palate. She was unhappy with the appearance of her temporary prosthesis, which appeared bulky, and was also concerned about the appearance of her teeth. The patient had a fixed partial bridge since the age of 18, following surgery to correct the bone defect associated with the cleft palate. She had been in the process of decay.
Superimposition with CBCT-Scan
An examination and radiographic analysis revealed root resorption on teeth #8, 9 and a cleft at site #10. Due to the cleft at site #10 the clinical attachment level on the distal of #9 and mesial of #11 was compromised.
The incisal to middle third of tooth #7 was also noted to be slightly darker in shade compared to adjacent teeth. Previous anesthetic injections in the area of the cleft have caused pain and discomfort in the lip and soft tissue.
As a Prosthodontist, I have planned a multi- stage treatment plan for the patient and will coordinate with other dental specialists. The patient has been referred to periodontics and her oral surgeon to address her periodontal disease and soft tissue lesion in the labial vestibule around the region of the missing tooth #10. The periodontist will address the generalized periodontal disease, while the oral surgeon will monitor the patient’s non healing lesion and provided treatment.
The patient will receive antibiotics to manage any infection, and he will map the pain of the maxillary lip/vestibule to help determine the cause of her dysesthesia of the upper lip. I also replaced the existing provisional restoration with improved contours to allow for better hygiene, and monitor the progression or resolution of the patient’s symptoms of dysesthesia of the upper lip. Once the patient’s periodontal disease and soft tissue lesion are addressed, I will proceed with restoring her teeth with a bridge and crowns #8 to 12.
- Root blunting teeth # 8,9
- Soft tissue lesion labial vestibule
- Dysesthesia of the left upper lip. Possible source: Scar tissue, necrosis, infection.
- Periodontal disease generalized
around the region of the deft palate
- Provisional restoration that is over contoured.
JENNIFER'S TREATMENT INCLUDED THE FOLLOWING STEPS:
• Comprehensive examination
• Map pain in upper lip and vestibule
• Fabricate new segmented provisional #8-12 to allow better hygiene and determine need for gingival replacement.
• Prepare tooth #7 for veneer and make final impression for #7-12
• Try-in and insert ceramic veneer #7,
• splinted zirconia crowns #8-9 and
• cantilever zirconia FPD #10-12
There were several challenges this case presented with the dysesthesia associated with previous anesthetic injections required careful management to minimize disruption of the area. Our solution to previous fracture of the FPD was to segment the restoration in two sections due to variable movement of cleft maxilla.
Esthetically, gingival porcelain was added for proper tooth proportions and to replace soft tissue defects. The final challenging aspect was the occlusion, to minimize excursive movements on periodontally compromised central incisors.
The challenge that a cleft presents, as you can see in this photograph, is the variable movement of the 2 sides which contraindicates a conventional bridge.
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