Oral Rehabilitation of a Patient With Complete Unilateral Cleft Lip and Palate Using an Implant-Retained Speech-Aid Prosthesis: Clinical Report

Transcription

1 Oral Rehabilitation of a Patient With Complete Unilateral Cleft Lip and Palate Using an Implant-Retained Speech-Aid Prosthesis: Clinical Report Amara Abreu, D.D.S., M.S.D., Daniel Levy, D.D.S., M.S.D., Enrique Rodriguez, D.M.D., Irma Rivera, D.M.D. Objective: To report the oral rehabilitation of velopharyngeal insufficiency due to a congenital anatomic defect using an implant-retained speech-aid prosthesis. Case Report: A 65-year-old man with a diagnosis of complete unilateral cleft lip and palate on the left side with an unrepaired palate was examined. A removable partial denture with a speech bulb had been used for approximately 40 years. After primary care for gross caries and tooth mobility, an implantretained obturator with a speech bulb was fabricated. Results and Conclusion: Improvement in mastication, speech, and velopharyngeal function was achieved with a satisfactory esthetic result. KEY WORDS: osseointegrated implants, speech-aid prosthesis, unrepaired palate Prosthodontic treatment of patients with orofacial clefts involves the restoration of dentition; speech rehabilitation, including velopharyngeal (VP) function; and improved esthetics. The VP valve mechanism regulates nasal resonance during speech and nonspeech oral activities such as swallowing, blowing, sucking, and whistling. VP dysfunction may be congenital, developmental, or acquired (Beumer et al., 1979; Shprintzen and Bardach, 1995). Impairment of VP function can be due to insufficiency or incompetency. VP insufficiency is distinguished by speech and nasal resonance abnormalities related to defects of the soft palate, which may be congenital as in cleft palate or acquired as in palatal tumor resection. VP incompetence describes dysfunction of an anatomically intact VP mechanism as in patients with neuromuscular disorders (Trost-Cardamone, 1989; Shifman et al., 2000). Several authors have described different types of prostheses to improve speech ability (Leonard and Gillis, 1990; Saunders and Oliver, 1993; Wolfaardt et al., 1993; Yoshida et al., 1993; Shifman et al., 2000). A speech appliance may prevent the hypernasality and/or nasal emission associated with VP inadequacies. With a speech appliance in place, the patient can exhibit adequate airtight separation between the oral and nasal Dr. Abreu is Instructor, Oral Rehabilitation Department, School of Dentistry, Medical College of Georgia, Augusta, Georgia. Dr. Levy is Assistant Professor, Department of Orthodontics, School of Dentistry, Medical College of Georgia, Augusta, Georgia. Dr. Rodriguez is Professor, Prosthodontic Graduate Program, School of Dentistry, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico. Dr. Rivera is in private practice, Los Angeles, California. Submitted September 2006; Accepted March Address correspondence to: Dr. Amara Abreu, Oral Rehabilitation Department, School of Dentistry, Medical College of Georgia, Augusta, GA aabreu@mcg.edu. DOI: / cavities during production of pressure consonants or while blowing with variable intensity (Tachimura et al., 2000). In addition, the appliance permits the levator veli palatini muscle to perform VP closure as well as facilitate changes in relation to oral air pressure during blowing as in normal speakers (Tachimura et al., 1999). Despite these advantages, retention of obturator prostheses is usually compromised because of the weight of the appliance and the inability to obtain a border seal. Speech and eating are more difficult because of lack of retention. However, Branemark introduced osseointegrated root form dental implants in 1983, which provided new treatment alternatives for solving problems related to edentulism (Harrison, 1992). Thus, implants may be used to support, stabilize, and retain fixed or removable prostheses and are extremely beneficial for maintaining alveolar bone (Adell et al., 1981). Implant-retained dentures, overdentures, and obturator prostheses have been used to treat patients with orofacial clefts who present with complete edentulism (Harrison, 1992; Matsui et al., 1993; Arcuri et al., 1994; Lefkove et al., 1994; Laine et al., 2002; Pham et al., 2004). This clinical report describes the prosthodontic rehabilitation of a patient with a complete unilateral cleft lip and palate, using an implant-retained speech-aid prosthesis to treat his VP insufficiency. CLINICAL REPORT A 65-year-old man was referred to the University of Puerto Rico, School of Dentistry, Prosthodontic Graduate Clinic, with the chief complaint of an ill-fitting removable partial prosthesis. The patient had a history of lip surgery at 12 years of age but claimed to never have had a palate closure. Oral exami- 673

2 674 Cleft Palate Craniofacial Journal, November 2007, Vol. 44 No. 6 FIGURE 1 left side. Occlusal view of the complete unilateral cleft palate on the nation revealed VP insufficiency secondary to a complete unilateral cleft lip and palate on the left side (Fig. 1). At age 24, he was treated with a tooth-supported removable partial denture with a speech-bulb portion and had worn this device for more than 40 years (Fig. 2). He presented gross caries and tooth mobility in the remaining teeth. The patient s speech was hypernasal, he was unwilling to smile, and his esthetic appearance was negatively affected. At the initial visit, the prosthodontist made preliminary impressions for diagnostic cast fabrication using a stock tray and extended the palatal portion with wax. The clinician employed irreversible hydrocolloid impression material (Jeltrate; Dentsply Caulk, Milford, DE) to record the tissues and the defect. Panoramic and periapical radiographs of the remaining teeth and extra and intraoral photographs were taken as well. Treatment Plan As the radiographs supported the clinical findings, the prosthodontic team formulated a treatment plan that was later approved by the patient. Based on the diagnostic cast, a custom-made acrylic tray (Triad Custom Tray Material; Dentsply International Inc., York, PA) was prepared. After border molding, the clinician made a second impression using a polysulfide impression material (Permlastic; Kerr Mfg. Co., Romulus, MI) and fabricated an immediate maxillary complete denture, which did not include the VP portion. A resilient denture liner (CoeSoft; Coe Laboratories, Inc., Chicago, IL) was added to the denture, and it was inserted intraorally after all remaining maxillary teeth were extracted. Three weeks after surgery, a self-cured acrylic extension (Jet Denture Repair Acrylic; Lang Dental Mfg. Co., Wheeling, IL) was added to the posterior area of the prosthesis. A peripheral impression material (New Rimseal; Bosworth, Skokie, IL) was then used to record the peripheral detail of the VP portion. This area was shaped by asking the patient to tilt his head side to side and front to back when sitting upright (Sandeep, 2006), given the influence of head position on pharyngeal activity. The patient also had to talk and swallow (Keyf et al., 2003) during the VP detailing stage. After the material FIGURE 2 Removable partial denture with speech-bulb portion that had been used for the past 40 years. had set, pressure areas during head movements, speech, and swallowing were identified with pressure indicator paste (Mizzy, Inc., Clifton Forge, VA) and removed. Two months later, the maxillofacial surgeon placed four 13- mm-length, 3.7-mm-diameter tapered implants (Tapered Screw-Vent; Zimmer Dental, Carlsbad, CA) in the maxillary alveolus. Six months later, the patient required a second-stage surgery for implant uncovering and healing cap placement. The provisional prosthesis was readapted after each surgery using a chairside hard denture relining material (Tokuso Rebase; J Morita USA, Inc., Irvine, CA). After the tissue healed completely around the healing caps, a polyvinylsiloxane impression (Aquasil Ultra Monophase, regular set; Dentsply Caulk) was made to permit fabrication of the implant-retained bars. The prosthodontist used tapered abutments for multiunit restorations (Zimmer Dental) and a direct impression technique (open-tray technique). Next, the laboratory technician adapted nonengaging 3.5- mm-diameter cast-to gold abutments (Zimmer Dental), and a Hader Bar semiprecision bar attachment (Sterngold Dental, LLC, Attleboro, MA) with semiprecision attachments (ERA- RV attachments; Sterngold Dental) located in the posterior portion of the bars for the final fabrication of the implantretained bars. A noble metal alloy (Pd-Ag, W-1; Ivoclar Vivadent, Inc., Amherst, NY) was used in casting the bars, which were then adapted to the master cast (Fig. 3). After the insertion of the implant-retained bars, a new impression was made with polyvinylsiloxane (Aquasil Ultra

3 Abreu et al., IMPLANT-RETAINED SPEECH-AID PROSTHESIS 675 FIGURE 3 Intraoral view of implant-retained bars. Monophase, regular set; Dentsply Caulk) using the black male ERA attachment connected to the female (already cast to the bar) and the riders for the Hader Bar. This cast was used to fabricate the metal frame of the obturator. Simultaneously, the prosthodontist prepared guiding planes and occlusal rests in the remaining mandibular teeth and made a final impression with alginate (Jeltrate; Dentsply Caulk). The final mandibular cast was used to fabricate a removable partial denture metal framework. At the next visit, metal try-in and teeth selection were carried out. After the wax try-in of both dentures, the clinician copied the palatal defect using modeling compound (Kerr Mfg. Co.). No previous measurements of the VP portion were made; therefore, the VP portion was molded in detail with the same material. Small increments of the compound were added each time. On every occasion, the patient tilted his head side to side and front to back sitting upright (Sandeep, 2006), as well as swallowed and talked to record every detail of the area (Keyf et al., 2003; Fig. 4A). The dental technician poured the altered cast impression (Fig. 4B) and processed the prosthesis in heatcured acrylic resin (Lucitone; Dentsply International Inc.; Fig. 5). When the maxillary and mandibular prostheses were inserted (Fig. 6A and 6B), pressure areas during head movements, speech, and swallowing were located with pressure indicator paste (Mizzy, Inc.) and relieved. Because of the buccal position of the implants on the right side and because of the width of the crest of the ridge in that area, there was not enough space for the acrylic of the denture base and the teeth. Therefore, facings were used in the posterior area of the right side, and the patient was required to occlude into the acrylic surface of the maxillary obturator on that side. The patient was educated in oral hygiene and instructed in the specific care for his new maxillary and mandibular prostheses. The checkups were done at 1 week, 2 weeks, 1 month, and 6 months after insertion of the prosthesis. During that time, there were no complaints regarding the patient s oral and prosthetic hygiene. The patient was placed on a 3-month recall to have the implant-retained bars and the remaining mandibular teeth cleaned. He was also made aware of the possibility that new retentive clips need to be placed as the original clips wear down. FIGURE 4 A: Impression of the palatal defect and the velopharyngeal area, using modeling compound. B: Altered cast of obturator prosthesis. DISCUSSION Patients with unrepaired cleft defects of the hard and soft palate represent a significant challenge in terms of treatment, especially when they present with an edentulous maxillary arch. Retention is usually compromised in obturator prostheses, and many patients complain of difficulties in speech and eating. Osseointegrated dental implants represent an invaluable alternative for these cases. In this instance, the patient complained of lack of retention of his old denture. Implants provided support and mechanical retention of the obturator prosthesis that was prepared. Several authors support this treatment

4 676 Cleft Palate Craniofacial Journal, November 2007, Vol. 44 No. 6 FIGURE 5 Processed denture. approach (Harrison, 1992; Matsui et al., 1993; Arcuri et al., 1994; Lefkove et al., 1994; Laine et al., 2002; Pham et al., 2004). Dental implant placement is a predictable surgical procedure with a very high success rate. However, an inaccurate implantation can lead to irreversible surgical damage or prosthetic failure (Shohat and Tal, 2005). At present, there are several computer-assisted guidance methods in implantology, such as Med3D (med3d AG, Zürich, Switzerland), codiagnostix (IVS Solutions AG, Chemnitz, Germany), and SimPlant (Materialise, Leuven, Belgium), which involve the fabrication of computer-assisted surgical templates. Similarly, systems such as the RoboDent intraoperative guided navigation method (RoboDent GmbH, Berlin, Germany) permit the transference of three-dimensional preoperative planning for the implant placement surgery (Mischkowski et al., 2006). Image-guided insertion of dental implants is significantly more accurate than manual insertion, but the accuracy that can be achieved with manual implantation is sufficient for most clinical situations (Brief et al., 2005). Therefore, computer-assisted dental implantology is currently reserved for difficult anatomical situations (Siessegger et al., 2001; Mischkowski et al., 2006). In our case, the maxillofacial surgeon did not consider it necessary to use a computerized method to guide the placement of the dental implants despite our patient s narrow maxillary ridge. Several prosthetic designs are available for the restoration of an edentulous maxilla. The literature reports the use of a continuous bar to splint all the implant abutments (Harrison, 1992; Pham et al., 2004). In our reported case, two separate bars were used because of the difficulty in achieving a passive fit. During fabrication of the implant-retained bars, the original pattern can distort for multiple reasons (Adell et al., 1981; Albrektsson and Lekholm, 1989). Dental implants form a very rigid system with the bone where they are osseointegrated. FIGURE 6 A: Maxillary prosthesis at insertion. B: Frontal view of patient s prostheses. Lack of passivity in the bar causes additional stresses and forces on the implants and the surrounding tissues, generating the risk of adverse biological reactions (Skalak, 1983; Rangert et al., 1989). These stresses lead to loosening of abutment screws and/or fractures of the screws or implants (Albrektsson et al., 1986; Cox and Zarb, 1987). Regarding proper prosthetic design, a previous study concluded that the combination of ERA attachments and Hader clips similar to the design used in our case report was considered to be the most retentive overdenture bar attachment design when compared to others (Williams et al., 2001). Other alternative prosthetic designs for the oral rehabilitation of this patient included the use of Spark Erosion technology. There is an improvement in the passive seat of the prosthetic elements by machining the framework with the Spark Erosion method using electrodischarge machining (Renner, 2000). However, these types of castings require highly trained technicians, and because of their high cost, they are not used in many patients (Brudvik and Chigurupati, 2002). Other design alternatives for this case involved the use of O-ring and ball attachments (de Carvalho et al., 2001), but since this system may not afford maximum retention for cases of congenital defects such as cleft palate, we chose not to use them as we considered that any design different from the one we selected would have been less retentive. Different impression materials such as polysulfide rubber (Harrison, 1992) or polyvinylsiloxane may be used for final

5 Abreu et al., IMPLANT-RETAINED SPEECH-AID PROSTHESIS 677 impressions in a case such as that reported here. The latter undergoes the least amount of dimensional change on setting of all elastomeric materials ( 0.1%), allowing it to be poured for up to 1 week after the impression is made, and it will also allow repeated pours (Anusavice, 1996; Mandikos, 1998). On the other hand, polysulfide rubber impression material is more restrictive than polyvinylsiloxane, including a prolonged setting time (8 to 12 minutes) and poor dimensional stability, requiring it to be poured within an hour and used only once (Anusavice, 1996). In this case, the palatal defect and the VP portion were molded using modeling compound (Kerr Mfg. Co.; Beumer et al., 1996). Other authors have reported adding impression wax (Kerr Mfg. Co.) to the modeling compound surface (Harrison, 1992) or zinc oxide eugenol impression material (Keyf et al., 2003) to make a functional impression. VP insufficiency in patients with orofacial clefts is associated with hypernasality, which can be corrected with the use of speech appliances (Tachimura et al., 2000). It is important to note that there were no objective measurements made in our patient, such as nasometric data and/or voice change in association with placement of the obturator. However, subjectively, he demonstrated a significant improvement in speech ability and VP function due to, in our opinion, the presence of a VP component in the obturator prosthesis. Overall, the esthetic outcome was satisfactory, and the patient was very pleased with his new smile. Acknowledgments. The authors extend sincere gratitude to Dr. G. Dave Singh and Dr. John Stockstill for their help with the manuscript. Dr. Gustavo Fadhel is thanked for his clinical advice and expertise. REFERENCES Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. 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