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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 3  |  Page : 202-205

Smile designing for cleft lip and palate patient: The prosthodontic approach


Department of Prosthodontics, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Maharashtra, India

Date of Web Publication7-Aug-2017

Correspondence Address:
Karuna Gajanan Pawashe
Department of Prosthodontics, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Malkapur, Satara, Karad-415539, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_43_17

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  Abstract 

The case report describes smile designing of a 22-year-old male patient who was surgically operated for unilateral cleft lip (left side) with Andrew's Bridge system. It is composed of two components: Fixed component (retainers on abutments joined by bar) and removable component. The patient exhibited maxillary anterior defect (Siebert's Class-III anterior ridge defect), teeth transposition, increased mesiodistal edentulous space, bilaterally missing lateral incisor. When there is a limitation of bone grafting/surgical augmentation, alternative treatment modalities such as removable partial dentures, fixed partial dentures with gingival porcelain and/or fixed-removable partial dentures known as Andrew's bridge are indicated.

Keywords: Andrew's bridge, anterior ridge defect, cleft lip, cleft palate, fixed removable prosthesis, smile designing


How to cite this article:
Pawashe KG, Tewary S, Sanyal PK, Khanna D. Smile designing for cleft lip and palate patient: The prosthodontic approach. Indian J Dent Sci 2017;9:202-5

How to cite this URL:
Pawashe KG, Tewary S, Sanyal PK, Khanna D. Smile designing for cleft lip and palate patient: The prosthodontic approach. Indian J Dent Sci [serial online] 2017 [cited 2019 Nov 14];9:202-5. Available from: http://www.ijds.in/text.asp?2017/9/3/202/212395


  Introduction Top


Medical and dental interventions improve appearance and function of patients' with congenital/craniofacial defects; having a profound effect on the individuals' happiness and productivity. Patients embarrassed by their teeth and facial appearance are frequently less motivated to maintain good oral hygiene or seek regular dental care, resulting in increased tooth loss and destruction of oral tissues; hence, exacerbating the existing problem. The early intervention can be extremely beneficial for patient's well-being. Patients' self-confidence is highly enhanced after prosthetic treatment.[1]

The collaborative triad of oral surgeon, orthodontist, and prosthodontist ensures satisfying outcome for protracted yet regular visiting cleft lip and palate (CLP) patients.


  Case Report Top


A 22-year-old male patient who was surgically operated for unilateral cleft lip (left side) and palate reported for replacement of missing anterior teeth after orthodontic correction. The complexity of the case is discussed below [Figure 1],[Figure 2],[Figure 3].
Figure 1: Pretreatment (front view)

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Figure 2: Labial mucous membrane fold (front view)

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Figure 3: Pretreatment and labial mucous membrane fold (occlusal view)

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Kennedys' Class III Mod-1 partial edentulous arch due to bilateral missing maxillary lateral incisors (12, 22). Siebert's Class-III anterior ridge defect and a bulbous fold of mucosa extending from the labial mucous membrane anteriorly to cover the complete cleft of the palate posteriorly. A substantial movement of this fold was visible during functional movements of the lip. Transposition of right central incisor (11) in place of right lateral incisor (12) and left central incisor (21) in place of right central incisor (11). The increased mesiodistal distance between left central incisor (21) and left canine (23). Reduced clinical crown height for left central incisor (21). Gingival zenith of 11, 21, and 23 was located at varying positions.

Smile designing was an adjunct to prosthetic replacement. Placement of single pontic would result in spacing and space for two pontics was inadequate. Thus, treatment plan decided was a transposition of 11 into 12, 21 into 11 and 23 into 22 respectively with 21 being the pontic.

Procedure

Maxillary and mandibular diagnostic impressions were made with irreversible hydrocolloid impression material (Tropicalgin, Zhermack) and poured with Type-III dental stone (Kaladent, Kalabhai Karson Pvt Ltd, Mumbai, India). Mock tooth preparation and wax-up were done on the study model to analyze final treatment outcome. Intentional root canal treatment for 11 and 23 was performed. To achieve uniform gingival zenith, crown lengthening procedure was performed for 21 [Figure 4] and [Figure 5]. Shade selection was done. Tooth preparation for 21 was done using conventional tooth preparation technique. Preparation for 11 was such that it resembled 12 and 23 resembled 22 [Figure 6]. The tooth to be replaced now (pontic) was a central incisor (21) instead of lateral incisor (22). The buccal surface of maxillary left first premolar (24) resembled the canine (23). Provisional restorations were placed. The patient was recalled for making final impression. Final impression was made with Addition Silicone (Aquasil Dentsply, Germany) and poured in Type-IV dental stone (Kalarock, Kalabhai Karson Pvt Ltd, Mumbai, India). The wax patterns for coping of prepared abutment teeth were fabricated. A plastic bar pattern (Alphadent Ceka Preciline, NV, Belgium) [Figure 7] was placed in the pontic section joining the distal aspect of wax pattern of 21 and the mesial aspect of wax pattern of 23 following the labiopalatal center of residual ridge with sufficient occlusal and tissue clearance. The entire assembly (wax patterns and bar) were sprued, invested, casted, and finished. The framework was checked intraorally for proximal contacts and occlusal relationships. Porcelain build-up [Figure 8] followed by bisque trial was done. Final glazing and cementation procedures were performed. Processing rider was placed on the bar, area cervical to the bar was blocked with putty, impression with irreversible hydrocolloid was made, and cast was obtained. Acrylic teeth were selected according to patient's age, sex, and personality and also from the adjacent porcelain retainers. The removable prosthesis was fabricated using heat cure acrylic resin (DPI Heat Cure, Mumbai, India) and space for the metal housing was created. Tissue adaptation and esthetics were checked. The plastic clip with metal housing was placed on the bar, autopolymerizing resin (DPI Cold Cure, Mumbai, Maharashtra, India) was added in the space created in the removable prosthesis and placed on the bar with plastic clip and metal housing. After the curing of resin, prosthesis was removed, and excess resin was trimmed and polished. Removable prosthesis was inserted [Figure 9] and [Figure 10], and postinsertion instructions were advised.
Figure 4: Varying gingival zenith positions-11, 21, and 23

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Figure 5: Gingival zenith and crown lengthening for 21

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Figure 6: Tooth Preparation for 11.21 and 23

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Figure 7: Components for Andrew's Bridge

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Figure 8: Fixed dental prosthesis

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Figure 9: Posttreatment extraoral profile

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Figure 10: Posttreatment

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  Discussion Top


Most commonly encountered congenital anomalies include CLP accounting to approximately one in 800 live births.[2] In general, they are classified into four major types: cleft lip, cleft palate, unilateral cleft lip, and cleft palate and bilateral CLP. The incidence of congenitally missing teeth, especially lateral incisors adjacent to the alveolar cleft is high.[3]

Quality and quantity of existing contiguous hard and soft tissues, systemic conditions, and economic status of the patient play a significant role in treatment planning, clinical outcome, and prognosis. The clinical situations in which surgical augmentation cannot be carried out on grounds of the systemic condition or reluctance for surgical procedure mandate the use of alternative treatment protocols such as removable partial dentures, fixed partial dentures with gingival colored porcelain, and fixed removable partial dentures known as Andrew's bridge.[4] It is indicated when there is ridge or jaw defect, either due to trauma and or surgical ablation and cleft palate patients with congenital or acquired defects.[5]

When there is a limitation of bone grafting/surgical augmentation, alternative treatment modalities are indicated. Conventional fixed partial denture treatment was not a treatment of choice for the patient due to the exaggerated movement of the labial mucous membrane fold during function. This would continuously exert pressure on the fixed partial denture and deleterious effect on the abutments. Hence, Andrew's bridge was selected as the preferred choice of treatment. The Andrew's bridge system is composed of two components: Fixed component (retainers on abutments joined by bar) and removable component.[3] Dr. James Andrews of Amite Louisiana (Institute of Cosmetic Dentistry, Amite, LA, USA) first introduced a fixed removable prosthesis.[6] The removable partial denture was not a choice of treatment since placement of clasps in the esthetic zone is not desirable for a young patient.[7] Since the abutments are strong enough to receive load, a fixed-removable partial denture in these situations offers both function and esthetics. When a comprehensive diagnosis and treatment plan is formulated Andrew's bridge provides a better therapeutic and emergency treatment.[7] Replacement along with an acrylic denture flange for tissue defects is an added advantage as it does not require special prosthesis for the gingiva as in fixed dental prosthesis. Since the prosthesis is retained by a bar retainer, the taste perception is unaltered as the flanges need not be extended palatally for support. The acrylic prosthesis can be removed by the patient when desired for hygienic access.[8] In this case, the support mechanism is shared by the tooth, and the tissues to some extent and the bar serves as a retentive and stabilizing tool for the removable segment. Another design of the prosthesis would be a complete fixed partial denture with an acrylic gingival prosthesis – gingival epithesis. However, such design makes the maintenance aspect extremely difficult.[9]


  Conclusion Top


The case report describes smile designing of a 22-year-old male patient with maxillary anterior defect, teeth transposition, increased mesiodistal space, bilaterally missing lateral incisor with Andrew's Bridge system. Andrew's bridge is the most acceptable treatment for a patient with missing teeth and ridge defect in CLP.

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.
Ayna E, Basaran EG, Beydemir K. Prosthodontic rehabilitation alternative of patients with cleft lip and palate (CLP): Two cases report. Int J Dent 2009;2009:515790.  Back to cited text no. 1
    
2.
Hickey AJ, Salter M. Prosthodontic and psychological factors in treating patients with congenital and craniofacial defects. J Prosthet Dent 2006;95:392-6.  Back to cited text no. 2
[PUBMED]    
3.
Ozlem A, Burcak K, Muhammet S, Bulem Y. Prosthodontic rehabilitation of cleft lip and palate patients with conventional methods – A case series. Int J Prosthodont Restor Dent 2013;3:120-4.  Back to cited text no. 3
    
4.
Rathee M, Sikka N, Jindal S, Kaushik A. Prosthetic rehabilitation of severe Siebert's Class III defect with modified Andrews bridge system. Contemp Clin Dent 2015;6 Suppl 1:S114-6.  Back to cited text no. 4
    
5.
Prasan KK, Joshi S, Shalini BN, Sowjanya K, Jessudass G. Achieving esthetics with Andrews bridge. Int J Prosthodont Restor Dent 2014;4:127-30.  Back to cited text no. 5
    
6.
Muthuvignesh J, Bhuminathan S, Egammai S, Narayana RD. Improving facial esthetics with Andrews' bridge: A clinical report. Int J Multidiscip Dent 2013;4:884-7.  Back to cited text no. 6
    
7.
DeBoer J. Edentulous implants: Overdenture versus fixed. J Prosthet Dent 1993;69:386-90.  Back to cited text no. 7
    
8.
Finley JM. Restoring the edentulous maxilla using an implant-supported, matrix-assisted secondary casting. J Prosthodont 1998;7:35-9.  Back to cited text no. 8
    
9.
Cura C, Saraçoglu A, Cötert HS. Alternative method for connecting a removable gingival extension and fixed partial denture: A clinical report. J Prosthet Dent 2002;88:1-3.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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Abstract
Introduction
Case Report
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