Cleft lip and palate; oronasal istula; prosthetic treatment; O ring attachment

Transcription

1 Open Journal of Clinical & Medical Case Reports Volume 4 (2018) Issue 6 ISSN Prosthetic treatment of a unilateral left cleft lip and palate with anoronasal istula: A case report Yesiboli Yeerken, DDS; Takafumi Otomaru, DDS, PhD; Mohamed Said, BDS, MPhil; Na LI, DDS, MDS; Yuka Sumita, DDS, PhD; Hisashi Taniguchi, DDS, PhD *Yesiboli Yeerken Department of Maxillofacial Prosthetics, Tokyo Medical and Dental University (TMDU), Yushima, Bunkyo ku, Tokyo , Japan Phone & Fax: ; yesiboli.yeerken@outlook.com Abstract A 52 year old man with a unilateral cleft lip and palate presented with a chief complaint of dif iculty for speech and chewing. He was missing some maxillary teeth and has a poorly itting prosthesis. After endodontic treatment was completed, we designed and provided the patient with a resin based removable prosthesis with an O ring attachment. In this report, we describe successful oral rehabilitation with this prosthesis, which improved mastication, oral health related quality of life, esthetics, and functional oral stability. Keywords Cleft lip and palate; oronasal istula; prosthetic treatment; O ring attachment Introduction Cleft lip and cleft palate, namely cleft lip (CL), cleft lip and palate (CLP), and cleft palate (CP) are one of the most common congenital anomalies birth defects that may impose a large burden on the health and quality of life [1] and often resulting in severe functional de iciencies in mastication and speech, as well as esthetics problems [2]. The goal of maxillofacial prosthetic treatment is correction of these issues [3]. Factors that must be considered in designing maxillofacial prostheses include missing teeth, intraoral anatomic deformities, occlusal vertical dimensions, and or onasal istula. The prosthetic options also depend on prior treatment. For example, in patients who have not had bone grafts, ixed prostheses and plumpers have reportedly lasted for more than 25 years [4]. After the 1990s, advances in surgery and orthodontic treatment improved the management of CLP, and ixed prostheses are usually provided to patients who have undergone secondary bone grafts. However, in patients with residual oronasal istula and partially or total edentulous maxillae, a conventional removable prosthesis has proved useful: are movable prosthesis with telescopic crowns and a removable prosthesis with stud attachments were reported [5,6]. This case report describes prosthetic treatment using a removable prosthesis with O ring stud attachments during the treatment and maintenance periods in a patient with CLP. Yeerken Y

2 Case report Vol 4: Issue 6: 1394 A 52 year old man with unilateral CLP presented to the maxillofacial prosthetic clinic at the Tokyo Medical and Dental University Dental Hospital with a chief complaint of dif iculty chewing and speaking and a poorly itting prosthesis in August The patient had been treated with lip plastic surgery at 6 months of age and palate plastic surgery at 4 years of age. He had received no postsurgical orthodontic or speech treatment. He reported dif iculty chewing and unsatisfactory esthetics because of missing teeth and an improperly itting prosthesis. Examination at the irst visit revealed that he was missing the following maxillary teeth: the left central incisor, left lateral incisor, and right irst and second premolars. He also had an oronasal istula at the cleft site, and an improperly itting prosthesis. In terms of de initive prosthetic treatment, we discussed with the patient various treatment options for the oronasal istula, including use of an implant, surgical closure, and prosthetic closure. The patient chose prosthetic closure (Figure 1,2) We provided him with a temporary removable prosthesis while all necessary endodontic treatment were completed. This temporary prosthesis prevented oronasal communication, restored masticatory and phonetic functions, and improved esthetics. Overall, this improved the patient's quality of life. We planned to design and it him with a de initive prosthesis after completing the necessary endodontic treatment. The irst resin based removable prosthesis was provided to improve leakage to the nasal cavity as soon as possible, and endodontic treatment was started. The prosthesis was a resin based denture with 0.9 mm Clasps of Cobalt Chrome (Co Cr) wire clasps to facilitate repair and adjustment, because we could not determine at the onset of the endodontic treatment whether the remaining teeth would be preserved or extracted. The prosthesis was adjusted at the same time as the initial endodontic treatment (Figure 3). Endodontic treatment was ordered at the endodontic clinic at Tokyo Medical and Dental University (TMDU) Dental Hospital and tooth extraction was ordered at the oral surgery clinic at TMDU. During the endodontic treatment, the patient requested esthetic improvement of the anterior part of the prosthesis. With this in mind, we designed a second removable prosthesis. The vertical dimension of occlusion was increased and the anterior over jet and over bite were changed. In January 2009, we planned the over denture for the anterior part of the prosthesis after endodontic treatment of the residual upper right central incisor, upper right lateral incisor, and upper right and left canines. We proceeded with adjustment of the prosthesis in parallel with the subsequent endodontic treatment to address the residual teeth (Figure 4). Based on X ray imaging, it appeared that the upper left irst molar could be preserved. However, the endodontist found a perforation of the root, such that preservation of the root would be dif icult. Thus, the tooth was extracted by an oral surgeon. After healing, drainage was continued from the extraction site and was further treated by the oral surgeon. After healed, we proceeded with the de initive prosthetic design. The following were delivered in September 2010: O ring attachments (Op anchor attachment, No.1, Hakuho, JAPAN) itted to the upper right and left canines, metal crowns itted to the upper right irst and second molars and left second molar, a resin based removable prosthesis with cast clasps itted to Page 2

3 Vol 4: Issue 6: 1394 the upper jaw (upper right irst molars twin hook, upper left second molars double cast clasp), and a metal based removable prosthesis (embrasure hook, mesial side rest, back action clasp) for the lower right missing teeth (Figure 5,6). After delivery of this de initive prosthesis, we adjusted leakage to the nasal cavity with auto polymerized resin (UNIFAST III Pink, GC Corporation, Tokyo, JAPAN), and the leakage improved. We saw the patient in follow up visits every 3 6 months. At these visits, we checked leakage to the nasal cavity, occlusal contact, oral hygiene of the abutting teeth, and the prosthesis. At the time of this report, the patient has had the prosthesis for 6 years (Figure 7). Discussion The patient was satis ied with oral function and esthetics after delivery of the de initive prosthesis. The prosthesis prevented oronasal communication, restored masticatory and phonetic functions, and improved esthetics, offering an overall improvement in quality of life. The previous removable prosthesis that the patient had irst visiting our clinic was a metal based denture that was dif icult to adjust to address the presenting problems. Choice of prosthetic rehabilitation options are based on the speci ic clinical situation and the patient's primary complaints and wishes. Clinical examination should include assessment of not only the dental condition but also oronasal communication. The prosthodontist should provide a prosthesis that is functional and easy to maintain. In this case, because a lengthy period was needed to complete all necessary endodontic treatment, the patient wore a resin based temporary removable prosthesis to temporarily address leakage to the nasal cavity. After the initial endodontic treatment, the patient required further esthetic improvement of the anterior part of the prosthesis. To address, the vertical dimension of occlusion was increased and the second prosthesis was delivered. Upon delivery, the remaining teeth still required treatment, so we inserted a temporary crown and denture. Before raising the vertical dimension, the patient was instructed about possible side effects, such as the tempo mandibular joint discomfort and discomfort with chewing and speech. The patient understood these risks and consented to one time bite resin. For the de initive prosthetic design of the upper jaw, we decided to design the anterior part of the prosthesis with an over denture rather than a ixed crown. This choice was based on the fact that the roots of the upper anterior teeth were short and there was a discrepancy between the upper and lower jaw, and thus alignment of arti icial teeth would be easier. In addition, because the studs were itted to the upper canines, the upper prosthesis became stable and prevented leakage. The treatment plan presented here consisted of maxillary rehabilitation using a new attachment, an implant [5,6], and telescopic crowns to seal the oronasal communication and restore dental occlusion. During discussion of the treatment options with the patient, one of the choices presented was the O ring attachment and resin based removable prosthesis for reasons of easier maintenance and repair If tooth abutment problems were to occur, and because of the patient's wish to avoid surgery. In the 6 years since providing the de initive prosthetic, the patient has had no problems with the remaining teeth or the removable prosthesis. Thus, the prosthodontic treatment may be considered successful. Page 3

4 Vol 4: Issue 6: 1394 Figures Figure 1: Oral cavity at irst visit. (A) Occlusal view of the oronasal istula at the cleft site; (B) Occlusal view of the prosthesis in position; (C) Frontal view without prosthesis; (D) Frontal view of the prosthesis in position Figure 2: Panoramic radiograph views of the irst visit; Figure 3: The irst treatment denture in position. (A) Occlusal view of the prosthesis in position; (B) Frontal view of the prosthesis in position; Page 4

5 Vol 4: Issue 6: 1394 Figure 4:The second treatment denture in position. (A) Occlusal view of the prosthesis in position; (B) Frontal view of the prosthesis in position Figure 5: Panoramic radiograph views of the 2 O ring attachment in position Figure 6:The view of the inal prosthesis. (A) Occlusal view without prosthesis; (B) Occlusal view of the prosthesis in position; (C) Frontal view without prosthesis; (D) Frontal view of the prosthesis in position Page 5

6 Vol 4: Issue 6: 1394 Figure 7: The view of the inal prosthesis after six years. (A) Occlusal view without prosthesis; (B) Occlusal view of the prosthesis in position; (C) Frontal view without prosthesis; (D) Frontal view of the prosthesis in position Conclusion An O ring attachment and resin based removable prosthesis stability was dramatically improved the patient's mastication, speech, oral health, and related quality of life. The patient was monitored every 3 6 months during the 6years since itting the prosthesis and he remains satis ied. Acknowledgement The part of the case report was presented at the 41st annual meeting of Japanese cleft palate association on May 18, 2017 and supported by JSPS and MOSR STDF under the Japan Egypt research Cooperative Program References 1. Wehby GL, Cassell CH. The impact of orofacial clefts on quality of life and healthcare use and costs. Oral Dis. 2010, 16(1): Regezi JA, Sciubba JJ, Jordan ROCK, editors. Oral Pathology, Clinical Pathologic Correlations. St. Louis, Missouri, Elsevier, Saunders: 2003, Hickey AJ, Salter M. Prosthodontic and psychological factors in treating patients with congenital and craniofacial defects. J Prosthet Dent. 2006, 95(5): Kanazaki A, Otomaru T, Sumita YI, Kosaka M, Haraguchi M, Hattori M, Murase M, Taniguchi H: Long term Observation of De initive Prostheses in Cleft Lip and Palate Patients. J. Jpn. Cleft Palate Assoc ; 40 (3): Palmeiro M R L, Piffer C S, Brunetto V M, et al. Maxillary rehabilitation using a removable partial denture with attachments in a cleft lip and palate patient: a clinical report. J Prosthodont, 2015, 24(3): Vojvodic D, Jerolimov V, Celebic A. Prosthetic rehabilitation of a cleft palate patient: a clinical report. J Prosthet Dent, 1996, 76(3): Page 6

7 Vol 4: Issue 6: 1394 Manuscript Information: Received: November 09, 2017; Accepted: March 27, 2018; Published: March 30, Authors Information: Yesiboli Yeerken, DDS *; Takafumi Otomaru, DDS, PhD ; Mohamed Said, BDS, MPhil ; Na LI, DDS, MDS ; 3 4 Yuka Sumita, DDS, PhD ; Hisashi Taniguchi, DDS, PhD ¹Graduate Student, Department of Maxillofacial Prosthetics, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan Assistant Professor, Department of Maxillofacial Prosthetics, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan ³Junior Associate Professor, Department of Maxillofacial Prosthetics, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan ⁴Professor and Head of Department of Maxillofacial Prosthetics, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan Citation: Yeerken Y, Otomaru T, Said M, LI N, Sumita Y, Taniguchi H. Prosthetic treatment of a unilateral left cleft lip and palate with anoronasal istula: A case report. Open J Clin Med Case Rep. 2018; Copy right statement: Content published in the journal follows Creative Commons Attribution License ( Yeerken Y 2018 Journal: Open Journal of Clinical and Medical Case Reports is an international, open access, peer reviewed Journal focusing exclusively on case reports covering all areas of clinical & medical sciences. Visit the journal website at For reprints and other information, contact editorial of ice at info@jclinmedcasereports.com Page 7