1; J. Holakovský
2; M. Bartoňová
2; M. Seydlová
1; Z. Šmahel
Department of Paediatric Stomatology, nd Medical Faculty, Charles University, Prague
1; Department of Stomatology, 1st Medical Faculty, Charles University, Prague, and
2; Department of Anthropology and Human Genetics, Faculty of Science, Charles University, Prague, Czech Republic
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 49, 4, 2007, pp. 89-93
on the statistical data, the mean incidence of all types of cleft defects in
the orofacial area is 1.86 per 1000
live-born children (9, 10). The number of the affected people in individual
years depends mainly on the birth-rate. The maximum number of children with
orofacial cleft was born in the Czech Republic in 1975, with 236 children with
orofacial cleft registered (9). Because of the low birth-rate in recent years
the number of affected children with orofacial cleft fell below 100. The
registry of hereditary defects was established in the Czech Republic in 1964
(5), and it currently has a record of more than 4500 families in Bohemia and
Moravia (1, 4).
integrated classification of cleft defects approved by the international
congress of plastic surgeons in 1967 in Rome divides clefts into three groups:
primary palate clefts, primary and secondary palate clefts, and secondary
palate clefts (11).
defects occur in all races, ethnic groups and families of all social classes
regardless of education level or their economic standard. However, there are
racial differences in the rate of clefts and incidence of single types of
lowest incidence of this defect is in the Black population (3). The Caucasian
population is affected by clefts approximately three times more often than the
Black, and Mongoloid population two times more often than the Caucasian
population. However, these facts apply for lip clefts with or without palate
clefts. As far as isolated palate clefts are concerned, their incidence in the
Caucasian and Mongoloid races is almost identical and it is markedly lower in
the Black population (3).
is unambiguously clear from the studies that investigated the incidence of
cleft anomalies in relation to gender that unilateral and bilateral cleft lip
and palate (CLPs) as well as unilateral and bilateral cleft lip (CLs) occur
more often in males. Males are affected almost twice as often as females. It
has been documented that isolated palate clefts (CPs) occurred more often in
females. As far as the laterality is concerned, unilateral clefts on the left
occur twice as often as on the right (2). A number of hypotheses exist to
explain these differences. However, they have not been verified completely. It
is stated that approximately 20% of cleft anomalies have a genetic basis;
environmental influences have been found to be associated with the affliction
in 10% of cases. The defect is supposed to be multifactor in the remaining 70%
of affected individuals (8).
to the extent of affliction, interdisciplinary cooperation is necessary and
usually complicated and long-term therapy, which is needed especially for
gradual growth of the jaw bones, is necessary. Therefore, the final solution
has to be postponed to a time when the arches are not in a growth period. The treatment should be
initiated with a surgical lip
correction (usually in the 3rd month of age of a child) and later with a correction
of the palate (between the 9th and 12th months of age). It
should be followed by orthodontic therapy that optimally achieves correction
(e.g. in an isolated palate cleft) but a final prosthetic solution is needed more often (especially in
complex clefts). A favorable
shape and size of the dental arches without anomalies is an important factor
for the prosthetic phase. A cleft defect often means that some teeth are
missing (lateral incisors, more often premolars) and there may be other
orthodontic anomalies which include either crossed occlusion, inverse occlusion
in the frontal part or various anomalies of a tooth position (inclination,
therapy (usually around 18 years of age) often leads to early loss of teeth and
in extreme cases to complete loss of dentition at between 40 and 50 years of
age. The prosthetic therapy of edentulous patients with a cleft defect is very difficult. There are
several reasons for difficulties during reconstruction and functioning of the
complete dental replacements: a discrepancy in the interrelationship between
the jaw bones especially due to maxillary hypoplasia, deformation and flat
embossment of palatal area, augmented by resilience of the thickened mucous
membrane and atypical tentacles of giant mucosal folds used for the closure of
these defects. The classical full dentures have no retention and stability.
of the implant supported edentulous dental arch is currently frequently used as
it provides a possibility of thorough functional and aesthetic therapy for a
patient. The treatment will be demonstrated using the IMPLADENT dental implant
system (LASAK, Ltd., Prague, Czech Republic). At least 6 to 8 implants have to
be inserted into an edentulous jaw. As soon as they are integrated (6 months), a surgeon performs
the X-ray examination (panoramic radiograph) and checks the grade of
osseointegration. Until this time the implants fixtures are still covered by
mucosa and sometimes they are also splinted using titanium splints. If a
surgeon is satisfied with the healing process, he cuts through the mucosal
cover (incision is made along the alveolar ridge) and looks for the cover screw
that closes the implants. Based on the implant size a suitable healing cap is attached (Fig.
1) and a prosthodontics will wait 1 to 2 weeks until the attached gingiva is
formed. The fixtures are located around the base of the upper jaw, which must
be formed functionally and aesthetically during the reconstruction according to
the shape of the natural dental arch.
preparation of an individual impression tray is the first prosthetic step
during reconstruction when performing metal-ceramic bridge. The alginate
impression of the upper jaw is performed and an open individual custom tray
from denture base resin is prepared in the laboratory. The open tray is
perforated in the sites of the future abutments. The alginate impression in the
opposite jaw bone is performed at the first visit and a plaster cast of the
opposite dental arch is within prepared in the laboratory. Furthermore, a wax
bite rim for determining of the intermaxillary relations is used.
dentist unscrews the healing caps during the second visit and screws on the
abutment (a prosthetic post for framework) (Fig. 2). He selects it according to
the diameter of the implant. He
further determines the insertion of the implant and hence the height of the
attached gingiva from 1 to 4 mm. A calibrated gauge is available for this
measurement. However, it is not necessary. The position of the abutments must
be checked using the X-ray image. Then, we attach the impression posts screwed
on using the special spines (Fig. 3). We try the impression tray so that the
posts freely pass through the openings in the tray (Fig. 4). The maxillary
ridge is impressed using the polyether impression material, the posts are
unscrewed and the impression is removed including the impression copings and
spines. The laboratory analogues are attached (Fig. 5) and it is dispatched to
the laboratory. A reconstruction of the maxillary relations using the wax bite
rim is a part of this visit (Fig. 6).
dental technician fills the impression using the silicone gingival mask and
creates the master model using the plaster type IV (stone) (Fig. 7). He seals
the working models with the reconstructed maxillary position into the
articulator. He attaches the combustible impression copings on the laboratory
analogues and finishes modeling the re-shape of the future construction. We
used a cobalt alloy in our case and prepared the construction according to the
instructions of the manufacturer (Fig. 8).
The technician must
continually view the free track of the screws of the future potentially removable
framework (Fig. 9). Because the jaw bone is cicatrices or contains defects it
is suitable to add not only hard but also soft tissues. As for the adjustment
of the vertical maxillary relation, the construction is often sectional with
the addition of pink ceramics simulating marginal gingiva (Fig. 10).
proving the metal framework, the bridge is completed using the ceramic
material. The final evaluation is done to see whether it fulfils the functional
and aesthetic requirements (Fig. 11). During the following few weeks
(adaptation phase) the screw holes are closed using cotton pellet over the
screw heads and glassionomer cement. The connection of the construction and
implants should always be checked using an X-ray image (Fig. 12, 13).
We can also use a
conditionally removable construction – veneered resin bridge (Fig. 14–16).
The problem in cleft
patients involves other diameter relations in the dental arch caused by the
defect alone or also by affecting the growth of the maxillary segment by
surgery. It was described that the width of the maxillary arch was higher
immediately after birth because the palate plates were not connected (7, 12).
However, the antero-dorsal diameter of the maxilla between the centre of the
papilla incisive and the tangent between the tubers maxillae is reduced from
birth to adult age (7). After surgery and when the patients grow, the dental
arches are narrower in the measured diameters between the conoides, premolars
and molars (6, 13).
A potentially removable
framework is therefore the main method of choice because the position of the
implants must be prosthetically modified. It allows not only to check the
implant, prosthetic bearing and mucous membrane but also to simulate the
insufficient amount of hard and soft tissues in the oral cavity. Therefore, it
is very suitable in cleft patients where we use implant support. The amount,
length and distribution are determined by the presence of the cicatrices
tissue. As presented, the biomechanics of the reconstruction enables individual
adjustment of the shape of the dental arch. The integration process is not
affected in this defect.
work has been supported by the Grant Institutional Research Plan IP FN Motol
No. 6307, PZO.00064203.
Tatjana Dostálová, M.D., Ph.D., DrSci, MBA
University, 2nd Medical Faculty,
of Paediatric Stomatology
00 Prague 5
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