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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 21-23

Functional and esthetic rehabilitation of an adolescent patient with palatal fistula and rotated maxillary central incisors


Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India

Date of Web Publication19-Nov-2018

Correspondence Address:
Dr. Astha Jaikaria
Room Number 310, Third Floor, Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, IGMC, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_13_18

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  Abstract 


Individuals with cleft lip and palate may experience problems with feeding, speaking, hearing, and social integration that can be corrected to varying degrees. This case report presents a method of restoration of form, function, and esthetics in a 14-year-old patient of cleft palate fistula. Interim hollow obturator was added to the lightness of the prosthesis along with adding resonance of speech and preventing regurgitation of fluids. Porcelain-fused metal crowns were also added to the overall esthetics of the patient that is one of the primary concerns during adolescence.

Keywords: Cleft lip and palate, hollow obturator, porcelain-fused metal crown


How to cite this article:
Jaikaria A, Thakur S. Functional and esthetic rehabilitation of an adolescent patient with palatal fistula and rotated maxillary central incisors. Indian J Oral Health Res 2018;4:21-3

How to cite this URL:
Jaikaria A, Thakur S. Functional and esthetic rehabilitation of an adolescent patient with palatal fistula and rotated maxillary central incisors. Indian J Oral Health Res [serial online] 2018 [cited 2018 Dec 10];4:21-3. Available from: http://www.ijohr.org/text.asp?2018/4/1/21/245672




  Introduction Top


Cleft lip and/or palate (CL/P) are the most common congenital malformations occurring in the craniofacial region, with a worldwide incidence of about 1/700 live births.[1]

Individuals with CL/P may experience problems with feeding, speaking, hearing, and social integration that can be corrected to varying degrees by surgery, dental treatment, speech therapy, and psychosocial intervention.[2]

Speech disorders are often caused by persistent structural anomalies such as velopharyngeal insufficiency (VPI), dental and occlusal problems, oronasal fistulas, and hearing problems.[3] The most common disorder of tone is that of hypernasality: The overall sound of the patient is “nasal.” The main cause of hypernasality is VPI, in which there is inadequate closure of velopharyngeal structures during speech.[4] Nonsurgical treatment options include prosthetic appliances such as a palatal training appliance or speech bulb or biofeedback speech treatment (particularly applicable in case of inconsistent pattern of closure). An obturator is a dental retainer with an “extension” designed to occlude the residual velopharyngeal gap occurring during speech.[5]

This case report presents a method of restoration of form, function, and esthetics in a 14-year-old patient of cleft palate fistula.


  Case Report Top


A 14-year-old male patient was referred to the Department of Pedodontics and Preventive Dentistry with the complaint of difficulty in eating, drinking, speech, and unaesthetic appearance during speech and smiling. His mother had a full-term, normal, uneventful pregnancy, and medical and dental history was not contributory. The patient had undergone surgery for bilateral cleft lip at the age of 1 year followed by palatal surgeries at the age of 3 and 7 years, respectively.

Intraoral examination of the child revealed bilateral cleft palate fistula involving hard palate in the midpalatine region and permanent dentition with retained deciduous teeth and mesially rotated (at an angle of almost 90°) maxillary central incisors [Figure 1].
Figure 1: Preoperative maxillary occlusal view of the patient

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  • Radiographs were obtained, and primary impressions were made. Orthopantomogram and occlusal view of the patient revealed retained left primary maxillary lateral incisors and left primary second molar and supernumerary tooth with respect to right maxillary central and lateral incisor [Figure 2]
  • Retained primary and supernumerary teeth were extracted. To place crowns that would mimic well-aligned maxillary central incisors in the arch, root canal treatment was planned for the two mesially rotated (at an angle of almost 90°) maxillary central incisors since the patient was unwilling for orthodontic intervention. Furthermore, bone support was inadequate in this region for orthodontic treatment
  • For the fabrication of an interim obturator with cleft palate, primary impression was made using alginate impression material in a stock tray (U-3). Impression was then poured, and a custom tray using transparent self-cure acrylic resin was built on the cast obtained from it. Numerous holes were made in custom tray
  • A secondary impression was made using rubber base impression material (addition silicone-heavy and light body) on the custom tray [Figure 3]a
  • The definitive impression was poured in dental stone to obtain definitive cast [Figure 3]b
  • A hollow obturator for the palatal defects was made using transparent self-cure acrylic resin using retentive components [Figure 4]a and [Figure 4]b
  • Root canal treatment was completed for both the teeth [Figure 5]. Crown cutting was done such that the mesial and distal surfaces of the central incisors were made to be the labial and lingual surfaces and vice versa. This was followed by porcelain-fused metal (PFM) crowns for both the teeth [Figure 6]a and [Figure 6]b.
Figure 2: Preoperative orthopantomogram and maxillary occlusal view radiograph of the patient

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Figure 3: (a) Final rubber-based impression of the patient. (b) Final cast obtained after pouring the final impression

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Figure 4: (a and b) Interim hollow obturator made of self-cure acrylic

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Figure 5: Preoperative and postoperative radiographs of root canal-treated maxillary central incisors

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Figure 6: (a) Postoperative maxillary occlusal view with interim obturator and porcelain fused metal crowns. (b) Postoperative maxillary frontal view of the patient

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  Discussion Top


Fistula rates reported in the literature range as high as 58% with a recurrence rate of nearly 33%.[6] Surgical management has been studied from the standpoint of timing (early vs. late)[7],[8] and staging[9],[10] but not by embryologic mechanism. Management of fistula in this case was delayed since the patient was not ready for any surgical repair at the given present time. Interim obturator prosthesis was thus delivered so as to relieve the patient of current problems during speech and regurgitation of fluids.

One of the most important factors from retention and stability point of view is the hollow bulb design consideration of the prosthesis. It contributes to lightness of the obturator which further improves the cantilever mechanics of suspension, avoids overburdening of adjacent soft tissue,[11] and adds resonance to speech.[12] Obturator and PFM crowns in the anterior teeth enhance the esthetics and speech of the patient, which are of major concern during adolescence.


  Conclusion Top


CL/P repair patients undergo psychological trauma since both speech and esthetics are affected. Hollow design of the obturator contributed to the improvement of speech as it added resonance while speaking. Modified crown cutting followed by modified crown position allowed improved esthetics to the overall appearance of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pigott RW. Organisation of cleft lip and palate services-results of a questionnaire. Br J Plast Surg 1992;45:385-7.  Back to cited text no. 1
    
2.
Farronato G, Cannalire P, Martinelli G, Tubertini I, Giannini L, Galbiati G, et al. Cleft lip and/or palate: Review. Minerva Stomatol 2014;63:111-26.  Back to cited text no. 2
    
3.
Sell D, Harding A, Grunwell P. A screening assessment of cleft palate speech: 'GOS. SP. ASS.' (Great Ormond Street speech assessment). Eur J Disord Community 1994;29:1-15.  Back to cited text no. 3
    
4.
Marsh JL, O'Daniel TG. Management of velopharyngeal dysfunction – A surgeon's viewpoint. Probl Plast Reconstr Surg 1992;2:73-85.  Back to cited text no. 4
    
5.
Farronato G, Giannini L, Riva R, Galbiati G, Maspero C. Correlations between malocclusions and dyslalias. Eur J Paediatr Dent 2012;13:13-8.  Back to cited text no. 5
    
6.
Landheer JA, Breugem CC, van der Molen AB. Fistula incidence and predictors of fistula occurrence after cleft palate repair: Two-stage closure versus one-stage closure. Cleft Palate Craniofac J 2010;47:623-30.  Back to cited text no. 6
    
7.
Lehner B, Wiltfang J, Strobel-Schwarthoff K, Benz M, Hirschfelder U, Neukam FW, et al. Influence of early hard palate closure in unilateral and bilateral cleft lip and palate on maxillary transverse growth during the first four years of age. Cleft Palate Craniofac J 2003;40:126-30.  Back to cited text no. 7
    
8.
Friede H, Enemark H. Long-term evidence for favorable midfacial growth after delayed hard palate repair in UCLP patients. Cleft Palate Craniofac J 2001;38:323-9.  Back to cited text no. 8
    
9.
Nollet PJ, Katsaros C, Huyskens RW, Borstlap WA, Bronkhorst EM, Kuijpers-Jagtman AM, et al. Cephalometric evaluation of long-term craniofacial development in unilateral cleft lip and palate patients treated with delayed hard palate closure. Int J Oral Maxillofac Surg 2008;37:123-30.  Back to cited text no. 9
    
10.
Stein S, Dunsche A, Gellrich NC, Härle F, Jonas I. One- or two-stage palate closure in patients with unilateral cleft lip and palate: Comparing cephalometric and occlusal outcomes. Cleft Palate Craniofac J 2007;44:13-22.  Back to cited text no. 10
    
11.
Brown KE. Clinical considerations improving obturator treatment. J Prosthet Dent 1970;24:461-6.  Back to cited text no. 11
    
12.
Kumar NS. Prosthetic rehabilitation of a complete bilateral maxillectomy patient: A technical report. Aust J Basic Appl Sci 2009;3:424-31.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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