Aesthetic Management of the Cleft Palate Patient

With the many new ideas and technologies being advanced, the current times are being referred to as the “golden days of dentistry.” Thousands of dentists around the world depend on textbooks, articles, Web casts, hands-on courses, and lectures to learn how to deliver aesthetic smiles to their patients. Digital diagnostics, dental implants, and CAD/CAM-fabricated restorations have provided today’s practitioners with treatment options capable of addressing a wide range of clinical conditions. Nevertheless, every clinician will occasionally encounter an extreme clinical challenge that taxes one’s ingenuity and expands accepted prosthodontic principles to new levels. The cleft palate patient can present such a challenge due to the considerations associated with aesthetic management.

BACKGROUND

Before. Facial view of cleft palate patient; she had undergone previous orthodontic treatment and requested a prosthodontic solution to improve her appearance. After. Postoperative view of the patient with a full smile demonstrates the improved facial aesthetics achieved through the “butterfly” restorative design.

There is a rich history in the dental literature describing prosthodontic treatment for patients with cleft lips/palates. These individuals often require care from multiple specialists (surgeons, orthodontists, speech pathologists, language specialists, dental technicians) over their lifetime, but treatment prognoses have improved considerably as dental and medical professionals have gained a better understanding of craniofacial growth.1


Treatment options for such patients can include positioning appliances, palatal obturators, surgical intervention, and other prostheses over time as they learn to function, prioritizing the development of normal speech, by performing reconstructive surgery prior to the onset of speech.2 Although early surgery is the preferred method of treatment to permit normal articulation development, prosthetic management provides an alternative treatment to promote more normal articulation development when early surgery is not planned.3

Patients with craniofacial anomalies may need intra- and extraoral orthopedic techniques to reposition the protrusive premaxilla prior to bilateral cleft lip.4 Radiographic, cephalometric, and clinical examination should be used to monitor these patients for proper orofacial development, and a full series of diagnostic records—including properly occluded study models—should be collected for periodic evaluation, as well as ongoing dental care and hygiene maintenance as a consequence of their medical condition. For some patients, orthodontic treatment may begin in adolescence and continue well into adulthood; such therapy may be combined with surgical correction of the facial deformity.5

Tracing the primary care of the cleft palate patient is not the focus, however, of this article. In the case presentation that follows, the authors present an innovative restorative approach used to provide aesthetic enhancement to a cleft palate patient. By applying a degree of ingenuity in the fabrication of leucite glass-ceramic restorations, the restorative team was able to provide considerable aesthetic improvement for the patient.

CASE PRESENTATION
Clinical Examination and Diagnosis

Figure 1. Preoperative view.

Figure 2. Preoperative buccal view of the right maxillary and mandibular dentition.

A 28-year-old female patient presented with a cleft lip and palate and requested aesthetic enhancement prior to her husband’s deployment to Iraq (Before Image and Figures 1 and 2). Comprehensive clinical and radiographic examinations were performed, revealing that the patient had previously undergone cosmetic surgery to correct her lip and orthodontic treatment. The patient history revealed that she was a mouth breather and, in order to prevent continuing gum irritation, it was recommended that the patient place a light coating of petroleum jelly on the facial surfaces of her gingival tissues before going to sleep at night. She demonstrated a Class III relationship preoperatively and overjet of 1 mm. In addition to large amounts of negative space bilaterally, the patient had a very narrow maxillary arch and had approximately 6 natural teeth in occlusion (Figure 3). Two of her teeth were in the palatal defect (Figure 4), but the patient declined the option of extraction since it might open up other issues. She had composite bonding that was deteriorating with recurrent caries. The patient had generalized gingivitis and moderate plaque accumulation.

Proposed Treatment Plan

  • Although the patient had undergone orthodontic therapy in the past, the prognosis of using this option at present was poor to guarded.
  • Treatment of the caries and removal of pre-existing composite resin bonding would be necessary prior to definitive restorative care.
  • Periodontal treatment would consist of laser-assisted gingival recontouring.
  • An aesthetic wax-up was created prior to treatment; this would determine the occlusal and aesthetic parameters for the patient as well as guide the laboratory technician in the creation of her definitive restorations.

Doctor-Technician Communication
A significant amount of preoperative communication was conducted with the dental laboratory technicians. Preliminary impressions, a bite registration, face-bow transfer, and photos were taken. Mounted study models and photos were then used to establish the patient’s current conditions. The lack of development of the maxillary arch created abnormal positioning of the teeth: approximately 6 teeth in occlusion, asymmetric gingival contours, and gingival overgrowth. A laboratory-fabricated diagnostic wax-up suggested the need for gingival recontouring, and the buildup the teeth buccally and occlusally. This would assist in achieving a more stable occlusion and lip support, more symmetric gingival contours, thus enhancing the patient’s aesthetics. A matrix made from the wax-up would be used to fabricate provisional restorations at the chair.

Clinical Treatment Begins
Nine maxillary teeth were ultimately prepared for pressed all-ceramic (IPS Empress Esthetic [Ivoclar Vivadent] crowns (Figure 5). Featuring butt joint margins and rounded internal line angles, the teeth were prepared using calibrated burs (NTI-Kahla GmbH), reducing approximately 1.0 mm of tooth structure, providing the dental technician with sufficient reduction needed to create natural aesthetics and optical effects in the porcelain restorations. Then, gingival recontouring was performed using a diode laser (Oddssey [Ivoclar Vivadent]) at 1.0 setting. For tissue retraction, Expasyl (Kerr) was placed for 10 minutes and then rinsed, and a No. 0 retraction cord (Patterson Dental Supply) was placed prior to taking the final impression. A polyvinylsiloxane (Virtual [Ivoclar Vivadent]) final impression was taken using the heavy and light-body (fast-set) material. Provisional restorations (Perfectemp [Discus Dental]) were made using the laboratory-fabricated matrix created from the diagnostic wax-up. Preparations were desensitized, spot-etched, and coated with ExciTE adhesive (Ivoclar Vivadent). The occlusion and margins were checked on the provisional restorations, and the embrasures were opened to ensure that the patient could use floss and use peroxide to maintain healthy gingival tissues. The patient’s aesthetics and function were then evaluated and verified 4 weeks after the preparation appointment. A new laboratory-fabricated diagnostic wax-up was requested because it was determined that the buccal corridors needed to be wider. After 2 weeks, the patient came back and the new diagnostic wax-up was presented. New custom temporaries were fabricated in order to assess function and aesthetics with the new design.

Delivery Appointment

Figure 3. When in centric relation, the maxillary and mandibular left molars and premolars were not in occlusion. Note the maxillary left has no existing table or scheme.

Figure 4. Occlusal view demonstrates 2 of the patient’s maxillary teeth were located in her palatal defect.

Figure 5. View of the maxillary anterior dentition following soft-tissue recontouring diode laser (Odessey [Ivoclar Vivadent]), caries removal and preparation for all-ceramic crowns.

Figure 6. Postoperative view of aesthetic enhancement achieved with 9 fixed prosthetic restorations (Empress Esthetic [Ivoclar Vivadent]).

Figure 7. The maxillary left and anterior teeth were created with a design that widened the buccal corridor, essentially cantilevering the occlusal scheme.

Figure 8. View of the right maxillary and mandibular segments following completion of treatment.

Figure 9. Without moving the existing dentition, aesthetics and occlusal harmony were achieved by cantilevering the buccal-lingual width of the anatomy.

After completion of the provisional phase of treatment, the all-ceramic crowns were returned from the dental laboratory, and the patient was ready to have the restorations cemented. Provisionals were removed and preparations disinfected with peroxide. The preparations were then cleaned with Consepsis (Ultradent Products) liquid and pumice in a rubber cup. Restorations were placed with trans (translucent) shade try-in paste (RelyX [3M ESPE]). The maxillary left and anterior dentition were built to create the effect of building out the patient’s buccal corridors, cantilevering the occlusal scheme to the buccal on both the left and right (Figures 6 to 8). With the final restorations in place with the try-in paste, aesthetics were approved by the patient. Then, the restorations were removed, cleaned, silanated, and cemented with RelyX Veneer cement (3M ESPE). Without bodily movement of the existing dentition, aesthetics and occlusal harmony were created with the use of cantilevering the buccal-lingual width of the anatomy, and the occlusal scheme, thus enhancing the smile and occlusion (Figure 9 and After Image).

Patient Follow-up Visits
The patient was periodically reappointed for one year to permit monitoring of the all-ceramic restorations, and her periodontal health. At 12 months following the periodontal and occlusion correction, the patient remained asymptomatic. The gingival inflammation was essentially resolved, and there was no evidence of occlusal trauma.

CONCLUSION
Dentists stand to bear witness to new advances that will further improve the management of the cleft palate patient. In particular, bone morphogenic proteins and tissue engineering seem promising. Using a creative and less-than-conservative approach, this extensive and comprehensive multidisciplinary treatment permitted the restoration of a severely compromised patient. All the patient’s existing teeth and remaining periodontium were preserved, and she was pleased with the aesthetics and stability of function that were achieved.

Acknowledgement
The authors wish to express their gratitude to Richard Willes, president/CEO of Utah Valley Dental Laboratory (Provo, Utah), and Susie Willes and the dedicated team of dental technicians for the fabrication of the restorations shown herein. Thanks also to Andres Sosa, DDS, for his research. Dentistry for this case was done by Debra Gray King, DDS.


References

1. Reisberg DJ. Dental and prosthodontic care for patients with cleft or craniofacial conditions. Cleft Palate Craniofac J. 2000;37:534-537.
2. Dorf DS, Curtin JW. Early cleft palate repair and speech outcome. Plast Reconstr Surg. 1982;70:74-81.
3. Dorf DS, Reisberg DJ, Gold HO. Early prosthetic management of cleft palate. Articulation development prosthesis: a preliminary report. J Prosthet Dent. 1985;53:222-226.
4. Figueroa AA, Reisberg DJ, Polley JW, et al. Intraoral-appliance modification to retract the premaxilla in patients with bilateral cleft lip. Cleft Palate Craniofac J. 1996;33:497-500.
5. Figueroa AA, Polley JW, Cohen M. Orthodontic management of the cleft lip and palate patient. Clin Plast Surg. 1993;20:733-753.


Dr. King received her dental degree at the University of Tennessee at Memphis in 1987. She has been an accredited member of the American Academy of Cosmetic Dentistry since 1995. She is one of only 5 women and 43 dentists worldwide that have also achieved the Fellowship status with the AACD. She is a graduate of the Las Vegas Institute of Advanced Dental Studies and has instructed at PAC-Live at the University of the Pacific in San Francisco, The Hornbrook Group and for the Aesthetic Masters where she taught cosmetic dentistry to dentists from across the country. She is a member of the American Dental Association, the Georgia Dental Association, the Northern District Dental Society, the Academy of General Dentistry, the Georgia Academy of Cosmetic Dentistry, the American Society for Dental Aesthetics, and the Hinman Dental Society. Dr. King was selected to perform smile makeovers on ABC’s hit show Extreme Makeover. Dr. King and her practice have been featured in Time, USA Today, The Wall Street Journal, Vogue, InStyle Magazine, and on CNN, CBS Morning Show and FOX News. Dr. King lectures across the country and continues to write numerous articles on cosmetic dentistry for various publications. She can be reached via e-mail at drking@georgiasmiles.com.

Disclosure: Dr. King reports no conflicts of interest.

Dr. Feinman is a founding and accredited member of the American Academy of Cosmetic Dentistry and visiting Scientist at the Hebrew University School of Dental Medicine in Jerusalem. As a Clinical Research evaluator—as well as being on the board of Reality and Practical Periodontics and Aesthetics—Dr. Feinman has been involved with the development and testing of many of the products which we use today. He has also held teaching positions at 6 universities, including one as a special lecturer in aesthetic dentistry at Emory University School of Dentistry in Atlanta, Georgia. Dr. Feinman has also been a spokesperson for cosmetic dentistry throughout the years, frequently appearing on CNN, WSB, and WAGA. He has authored and co-authored 2 textbooks, published numerous articles, and lectured throughout the world on the subjects of aesthetics, dental products, and operative dentistry. Dr. Feinman can be reached via e-mail at rafdmd@aol.com.

Disclosure: Dr. Feinman reports no conflicts of interest.