International Dental & Medical Journal of Advanced Research (2017), 3, 1–4

CLINICAL TECHNIQUE

Prosthodontics rehabilitation using palatal expander for a

child with ectodermal dysplasia
Ahmad Moutaz Attar1, Jamal Dabbas2, Hamzah Abbas1
Department of Prosthodontics, Faculty of Dentistry, University of Aleppo, Syria, 2Department of Orthodontics, Faculty of Dentistry, University of Aleppo, Syria
1

Keywords Abstract
Ectodermal dysplasia, complete denture, Background: This clinical report describes the use of the palatal expander which is
palatal-expander
incorporated into the mid-palatal region of the complete maxillary denture for a 4-year-
old complete edentulous patient. Heat polymerized acrylic resin was used to process
Correspondence
Dr. Ahmad Moutaz Attar, Department
both maxillary and mandibular denture. The completed dentures were polished and
of Prosthodontics, Faculty of Dentistry, finished. The palatal expander (max: 6 mm and full turn: 0.8 mm) was added to the mid-
University of Aleppo, Syria. palatal region of the maxillary denture during waxing and processing the dentures. The
Phone: +963956977228. design of this expander was invented by Haas (1965) max: 6 mm and full turn: 0.8 mm.
Email: a.moutaz.attar@gmail.com Medical grade adhesive was used for prosthesis retention.
Aim: The aim of this case report is to use the palatal expander to simulating the growth
Received: 03 January 2017; and development of mid-palatal suture and helping to normalize the masticatory function
Accepted: 02 February 2017 and perioral muscles movement, and as a result, the growth pattern of basal bones.
Conclusion: The technique of incorporated palatal expander into the mid-palatal
doi: 10.15713/ins.idmjar.59
region of the complete removable dental prostheses helped the clinicians and child to
get the advantages of this technique by facilitating the clinical and laboratory procedures
during follow-up appointments.
Clinical Significance: This technique was used to get benefit from the denture as long
as possible before rebasing or remaking a new denture.

Introduction alveolar ridges. The higher number of missing teeth affected

Ectodermal dysplasia (ED) is congenital disorder that is
described as large were initially described by Thurnam in 1848
and then Darwin in 1875.[1,2] 1/100000 births is characterized by
the abnormal development of the ectodermal.[2] ED appear to be
geneticin etiology and have two different forms named Clouston
syndrome (autosomal inherited form) and Christ-Siemens
syndrome (hypohidrotic form).[1] The disease affects both males
and females.[1]
The disease affects skin, saliva, hair (atrichosis or
hypotrichosis), sebaceous and sweat glands (anhidrosis or
hypohidrosis), nail and teeth (anodontia or hypodontia).[1]
About 80% of ED patients have been associated with dental
abnormalities.[3] Dental abnormalities were observed in ED
such as anodontia, hypodontia, misshapen teeth, taurodontism,
supernumerary teeth, neonatal teeth, natal teeth, retained primary
teeth, enamel hypoplasia, and resorbed alveolar ridge.[3] The
second most frequently occurring oral symptom is hypodontia
of both the primary and permanent dentition associated with
hypoplasia of the alveolar bone structures and poorly formed
from ED is in the mandible. In the primary dentition, the teeth
most commonly present are maxillary second molars, canines,
central incisors, and mandibular canines.[4] In the permanent
dentition, severe maxillary hypodontia has proven to be related
to craniofacial dysmorphology that affected on the cranial base
and mandibular length in the male ED population.[4] According
to Guckes et al.,[3] the maxillary central incisors (42%) followed
by the maxillary first molars (41%), Moreover, mandibular first
molars (39%) were the most permanent teeth to be present in
ED patients.[3] Mandibular anterior teeth were the least likely
to be present.[3] In addition to the absence of teeth, ED can also
lead to underdevelopment of the jaws.[3] With little or no dental
support, hypoplastic maxilla and mandible result in bite collapse
and narrowing of the alveolar ridges. This condition affects on
the facial esthetics by producing a collapsed appearance of the
lower third of the face.[3] According to Enlow,[5] mid-palatal
suture contributes only a meager amount to increase in width.[5]
The intermaxillary suture, according to Melsen,[5] is smooth and
open in children (6-8 years), in early adolescence (10-12 years)

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Palatal expander incorporated into the denture for edentulous child Attar, et al.

the sutural edges are overlapping, but in late adolescence

(14-16  years) the sutures become interdigitated and fused.[5]
Persson and Thilander found that earliest obliteration in male
was in a 21 years and no obliteration at all in a 32-year-old male.
[6]
According to Sperber obliteration may start in adolescence but
complete fusion is rarely found before 30 years.[7] We use the Haas
expander which consists of a metal framework with an expansion
screw in the palatal vault and acrylic pad on the palatal tissue,[8]
when the expansion of the maxillary denture is needed.[8] The
vertical and sagittal skeletal relationship will be improved by oral
rehabilitation of the hypohidrotic ED patient during craniofacial
growth and development, as well as to increase improvement of
the efficiency of esthetics, speech, and masticatory functions.[4]

Clinical Report Figure 1: Intraoral examination revealed total anodotia

A 4-year-old edentulous child was referred to the Department
of removable prosthodontics at the School of Dentistry at the
University of Aleppo for prosthetic assessment. His medical
record revealed a history of ED and he exhibited the classical
features of hypohidrotic ED including diffusely sparse hair,
eyelashes, eyebrows, severe hypohidrosis, and dry skin. The
facial profile showed a sunken nasal bridge (so-called “saddle
nose”), with prominent forehead and lips were everted. The child
was complained from nutrition, speech, and esthetic problems
due to the absence of his teeth [Figure 1]. The vertical occlusal
dimension loss (VDL) was cleared after extra oral examination
[Figures 2 and 3]. Panoramic radiographs [Figure  4] show
the dentition and bone appearance and confirmed the clinical
findings. The alveolar process was atrophic in all edentulous
areas. Vertical alveolar growth was occurred with development
of the permanent unerupted right maxillary first molars.
Radiographically, severe resorbed mandible and maxilla were
Figure 2: Lateral facial photo without dentures shows a decrease in
observed at the “D” level of the Misch classification (Severe facial height
resorption e bone only at basal level) [Figure 4].[9] A complete
overdenture retained by implants was the first suggestion, but this
suggestion was canceled because of severely resorbed mandible
and maxilla. Treatment options were discussed with various
dental specialists, and then a traditional mandibular complete
denture and a maxillary complete denture with an incorporated
palatal expander into the mid-palatal region were determined to
be the treatment of choice. This technique was used to simulate
the growth of mid-palatal suture to help to get benefit from the
denture as long as possible before rebasing or remaking a new
denture. Preliminary impressions of the edentulous arches
were made with irreversible hydrocolloid (Hydrogum Alginate;
Zhermack) and poured with Type  IV dental stone (Fujirock;
GC Corp). Individual trays were made with auto polymerizing
acrylic resin (Vertex; self-curing acrylic resin) for a definitive
impression. Border molding was taken with modeling plastic
impression compound (impression compound; SS white), then
the definitive impression was made with zinc oxide eugenol paste Figure 3: Frontal facial photo without dentures shows aged wrinkles
(ZOE impression paste; SS white) and poured with Type  IV around the lips
dental stone (Fujirock; GC Corp). According to esthetic and
functional principles, record bases with occlusion rims were made casts were mounted in an articulator using facebow records after
and adjusted for determining of the intermaxillary relations. The a centric relation interocclusal record was obtained. Modified

2 International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 2017

Attar, et al.
artificial teeth (Acryrock) were arranged and evaluated in the
mouth of the child to verify the esthetics, lip support, occlusal
vertical dimension (OVD), maximum intercuspation, and
phonetics. Prosthetic primary teeth were chosen to achieve an
age-appropriate appearance for the child. The occlusion and
position of the prosthetic teeth were evaluated intraorally, and the
necessary corrections were made before processing the dentures.
Heat polymerized acrylic resin (Vertics; heat-curing acrylic resin)
was used to process both maxillary and mandibular denture
[Figure 5]. The completed dentures was polished and finished.
The palatal expander (medium expander, IOS) (max: 6 mm and
full turn: 0.8  mm) was added on the mid-palatal region of the
maxillary denture during waxing and processing the dentures. The
design of this expander was invented by Haas (1965)[10] (medium
expander, IOS) max: 6  mm and full turn: 0.8  mm [Figure 6].
Then maxillary and mandibular complete dentures were inserted
[Figure 7]. Medical grade adhesive (Bony plus) was used for
retention. The child was instructed to follow an oral hygiene
regimen. Finally, the child and his parents were informed that the
screw of the palatal expander should only be turned if instructed
by his orthodontist and prosthodontist. Medical grade adhesive
(Bony plus) was used for prosthesis retention. In the 3rd and
4th weeks, the palatal expander was reactivated after bisecting the
maxillary denture and the screw was turned. Then the maxillary
Figure 4: Panoramic radiograph right maxillary permanent molar
is present
Figure 5: Age-appropriate inferior-complete denture
International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 20173
Palatal expander incorporated into the denture for edentulous child
denture was relined again in the direct way (chairside) using auto
polymerizing acrylic resin (Tokoyama self-curing acrylic resin).
The flanges were trimmed and the undercuts was removed.
The new relining material (Tokoyama self-curing acrylic resin)
was then mixed and applied to the fitting surface. The maxillary
denture was inserted and the patient was asked to bite gently on
the denture to ensure that the occlusion was not altered by the
procedure. The palatal expander was reactivated at the rate of
one-quarter turn of the screw (0.25 mm) every 3-4 weeks [Figure
8]. The rate of one-quarter turn of the screw (0.25  mm) every
3-4 weeks, the ratio of device to skeletal expansion is about 1 to
1.[11] After 1 month follow-up appointment, only minor problems
were reported during the adaptation period and also significant
improvements in speech, esthetics, and general well-being,
including facial appearance, and quality of life of the child. Follow-
up evaluations were made at 3, and 6 months after delivery of the
dentures. No functional or esthetic complications were noted
Figure  6: Palatal expander is incorporated into age-appropriate
maxillary complete denture
Figure 7: Age-appropriate complete denture in place
Palatal expander incorporated into the denture for edentulous child
Figure 8: Age-appropriate maxillary complete denture in place after
activating the palatal expander
at the appointment of assessment. The author suggests that the
dentures should not be worn by the child for more than 12 h a
day to protect him from restraining the growth of the mid-palatal
suture. Restraining the growth of the mid-palatal suture can result
from wearing the dentures for a long period of time.
Discussion
The described treatment can facilitate the clinical and
laboratory procedures and can reduce the financial expenses
by reducing the number of times which was needed to remake
the dentures during the maxillofacial growth of the child.
The technique was developed because of several reports of
replacing denture during a follow-up this kind of patients.
The traditional mucosa-borne prostheses have less retention
than implant supported overdentures. The technique needs a
frequently maximal intercuspation adjustment, especially when
reactivating the palatal expander. These facial disfigurements
were restored by prosthetic rehabilitation may improve the
level of function and self-esteem for patients.[12] As a result
of the anodontia, the mandible tends to be habitually located
more anteriorly[13] which probably the main cause for VDL.
The OVD of the patient was improved by the described
treatment. The determinants of facial esthetics are the sagittal
profile of the lower third of the face; lip morphology, facial
tissues appearance, and teeth display. These observations have
been confirmed clinically.[13]
Summary
The technique of incorporated palatal expander into the mid-
palatal region of the complete removable dental prostheses is an
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4
Attar, et al.
alternative procedure for removable dental prostheses that are
used in young patients with hypodontia to simulate the growth
and development of mid-palatal sutures and facilitate the clinical
and laboratory procedures during follow-up appointments. New
prosthetic therapy for children with ED was provided by a unique
opportunity for a participating effort among the pedodontist,
orthodontist, and the prosthodontist.
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How to cite this article: Attar AM, Dabbas J, Abbas H.
Prosthodontics rehabilitation using palatal expander for a child
with ectodermal dysplasia. Int Dent Med J Adv Res 2017;3:1-4.
International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 2017