“Rehabilitation of a congenital combined hard and soft cleft palate in an adult patient

using a prosthetic obturator relined with a long term reliner: A Case Report”

Abstract

Cleft palate in an adult patient is not a rare finding in a developing country due to lack of
awareness of the treatment procedure and financial restraints. Cleft palate in an adult patient
occurs either due to lack of any surgical intervention or a failure to repair the cleft. Cleft
palate leads to immeasurable difficulties including oral abnormalities, nasal regurgitation,
hypernasality of speech, compromised esthetics and psychological problems. This case report
entails the fabrication of a prosthetic obturator relined using a long term reliner for the
management of a combined palatal defect in an adult patient.

Keywords: Adult cleft palate, Hypernasality, Obturator, Reliner, Quality of life.

Introduction

Cleft palate is one of the most common congenital defects affecting the palate resulting in an
abnormal communication between the oral and nasal cavities. Congenital palatal defect leads
to substantial amount of problems including oral anomalies, difficulty in deglutition,
mastication, speech, and esthetic deformities. [1,2] Adult cleft patients who have not undergone
any surgical interventions or have undergone unsuccessful attempts at cleft repair in
childhood experience oronasal communication resulting in dysphagia, hypernasal speech and
impaired masticatory function.[3]

The growth and abnormalities of the facial bones are specifically impacted by the failure of
bone and matrix fusion caused by the cleft from the embryonic stage through full growth. The
facial bones have a normal capability for growth, despite being malaligned in cleft patients.
Following surgical repair, growth abnormalities, particularly midface retrusion, are a frequent
occurrence in cleft patients. Studies on adult cleft patients who have not undergone any
surgical procedures have revealed that the majority of them have normal development
potential with maxillary protrusion on the noncleft side. [4] This case report discusses the
prosthetic management of an adult cleft palate patient using a removable obturator relined
with a long term reliner.

Case Report

A 55-years-old male reported to the department of prosthodontics with the chief complaint of
looseness of the removable prosthesis and wanted a similar replacement of the prosthesis
with a better fit. Extraoral examination revealed a mid-facial collapse with deviation of the
nasal septum. Intraoral examination revealed a combined hard and soft palate defect (Figure
1A) with multiple missing teeth in both the upper and lower arches (Figure 1B,C). Various
treatment options including surgical procedures, implant-supported prosthesis, metal-based
prosthesis, two-part prosthesis, hinged prosthesis and relined removable obturator were
advised to the patient. Patient was willing for a relined prosthetic obturator, so this was
chosen as the treatment modality. An informed consent was obtained from the patient
regarding the treatment protocol.
Figure 1: A) Intraoral maxillary view showing the defect in both hard palate and soft
palate, B) Intraoral mandibular view, C) Pre-rehabilitative frontal view, D) Primary
impression of the maxillary arch, E) Primary impression of the mandibular arch, F)
Primary maxillary cast.

Primary impressions of the maxillary (Figure 1D) and mandibular arches (Figure 1E) were
made using the irreversible hydrocolloid impression material (Imprint, DPI, India) and the
casts were obtained (Figure 1F). Special trays were fabricated and the definitive impressions
was made using the dual impression technique with the medium body and putty consistency
addition silicone impression material (3M ESPE, Soft Putty, USA). The definitive casts of the
maxillary (Figure 2A) and mandibular arches were obtained (Figure 2B). The occlusal rims
were fabricated and the jaw relation was recorded (Figure 2C). The facebow was transfer was
carried out and mounting of the occlusal rims was done on the semi-adjustable articulator
(Hanau Wide Vue, USA) (Figure 2D). The teeth arrangement was carried out using artificial
anatomic acrylic teeth. The try-in was done followed by curing of the prosthesis in a
conventional manner. The final prosthesis was obtained followed by finishing and polishing
of the maxillary (Figure 2E,F) and mandibular prosthesis (Figure 3A).
Figure 2: A) Definitive maxillary cast, B) Definitive mandibular cast, C) Recording of
jaw relation, D) Mounting of occlusal rims on semi-adjustable articulator, E & F) Views
of definitive prosthesis.

A long-term chair-side relining material (Molosil, Soft relining, Germany) was used to
enhance the retention of the prosthesis (Figure 3B). Adhesive was applied followed by
mixing of both the base and catalyst pastes of the relining material in a ratio of 1:1. The
material was applied on the obturator portion of the prosthesis and inserted into the oral
cavity of the patient. The material was allowed to set and prosthesis was retrieved on setting
(Figure 3C). The extra flash was removed and the prosthesis was inserted in the oral cavity of
the patient (Figure 3F).
Figure 3: A) Maxillary and mandibular definitive prosthesis, B) Armamentarium for
relining prosthesis, C) Prosthesis relined with long-term relining material, D) Previously
worn prosthesis, E) Definitive maxillary prosthesis, F) Post-rehabilitative frontal view.

Post-operative instructions regarding the oral and prosthesis hygiene were given to the
patient. The patient was kept on a regular follow-up and necessary modifications were carried
out. Patient was satisfied with the outcome of the treatment (Figure 4A,B).

Figure 4: A) Pre-rehabilitative smile view, B) Post-rehabilitative smile view.

Discussion

Reconstructive prosthodontic treatment with removable prosthesis is a crucial component

when an adult patient with cleft palate reports with no or inadequate treatment. A cleft palate
has a negative impact on the appearance of the individual, which may result in
sociopsychological repercussions.[5] The degree of retention provided by the obturator
prosthesis depends on the direct and indirect retention offered by remaining natural teeth, the
presence of tissue undercut around the defect, the size of the defect, and the maturation of
muscular control. There will be varying degrees of undercut along the defect into the nasal or
paranasal cavity depending on site of the palatal defect. The extension of the prosthesis into
the defect serves as a resistance against both vertical and horizontal displacement. [6,7] Implant
supported prosthesis is a better treatment modality but is not feasible taking into the
consideration the general medical condition of the patient and the financial restraints.

The restorative dentist faces a difficult challenge when it comes to the prosthetic
rehabilitation of adult patients with unrepaired cleft palates. In such cases, removable
obturator dentures are a relatively easy treatment option where one relies on the tissue
undercuts and the border seal along the oronasal defect for retention and stability of the
prosthesis. The functional adaptation of the impression material and the functional contouring
of the palatal defect are essential factors to the success of the soft palate defect prosthesis.
This is accomplished using the resilient soft liner. It is capable of being employed as a
functional impression and has viscoelastic qualities. [8,9] This case report discusses a simple,
effective, convenient, feasible and cost-effective management of an adult patient with cleft
palate leading to formation of separate oral and nasal cavities. The prosthetic obturator led to
improvement in the hypernasality of speech, effective mastication and ultimately enhancing
the quality of life of the patient.

Conclusion

Rehabilitation of a cleft palate in an adult patient must be managed while taking both the
psychological and prosthetic treatment into consideration. The simple, cost-effective and
feasible approach used in this case report reduces the numerous oral problems and enhances
the quality of life of the patient.

References

1. Phalke N, Goldman JJ. Cleft Palate. [Updated 2022 Sep 26]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan.
2. Arshad M, Ameri N, Heidari A, Shirani G. Dental rehabilitation of a cleft lip and
palate patient by implant-supported overdenture: A case report. Clin Case Rep.
2020;8:1932–1936.
3. Vyas T, Gupta P, Kumar S, Gupta R, Gupta T, Singh HP. Cleft of lip and palate: A
review. J Family Med Prim Care. 2020;30;9(6):2621-2625.
4. Narayanraopeta S, Vemisetty HK, Marri T, Konda P. Rehabilitation of a Unilateral
Cleft Palate with Endosseous Implants in an Edentulous Elderly Patient. Contemp
Clin Dent.2020;11(3):285-289.
5. Guven O, Gurbuz A, Baltal E, Ylmaz B, Hatipoglu M. Surgical and Prosthetic
Rehabilitation of Edentulous Adult Cleft Palate Patients by Dental Implants. Journal
of Craniofacial Surgery.2010;21(5):1538–1541.
6. Krezel JD, Friel T, Waia S, Clark P, Taylor PD. Prosthetic Rehabilitation of a
Repaired Cleft Palate with Use of a Two ‐Part Hinged Magnet Retained Removable
Prosthesis. Journal of Prosthodontics.2021;30(5):454–457.
7. Yenisey M, Cengiz S,Sankaya ∣.Prosthetic Treatment of Congenital Hard and Soft
Palate Defects. The Cleft Palate-Craniofacial Journal.2012;49(5):618–621.
8. Varghese K. Prosthetic Rehabilitation of a Congenital Soft Palate Defect. J Indian
Prosthodont Soc. 2014;14(1):181-6.
9. Sheldon W (2009) Essentials of complete denture prosthodontics, 2nd edn. AITBS
publishers, India, pp 81–87.