Contests The Prosthocontest 2019/ 4 May 2019/

Case 6 | Leonardo Siguencia – Ecuador | Prosthocontest2019

Leonardo Siguencia Oral Rehabilitator

Karla Vallejo Oral Rehabilitator, Paul Cerda Periodontist, Marco Medina Periodontist.

SUMMARY

Most of the dental treatments that are performed today is aesthetically since most patients need an improvement in their quality of life and self-esteem, therefore, great importance has been given to the smile as a fundamental factor of said wellness.

Patient male 33-year-old, who came to the consultation with the desire to improve his smile, because he has a cleft palate that was operated on years before surgery, and orthodontic treatments themselves that led to loss of insertion of pieces 11, 12, 21, 22. The objective of the present clinical case is to perform a treatment between the periodontist and the oral rehabilitator in order to restore function and aesthetics to the upper anterior parts (11, 12, 13, 21, 22, 23, 24) and improving the patient’s smile.

Objective: To carry out a multidisciplinary treatment between the Periodontist and the Oral Rehabilitator, in a patient with cleft palate; in such a way that there is a work protocol which leads to a correct execution of the treatment which benefits the patient.

Conclusions: With this type of multidisciplinary treatment, the functional and, above all, aesthetic part of the patient was improved, while the quality of life of the patient with cleft palate was very good.

Key words: Cracked palate, connective graft, particulate bone graft, implants.

INTRODUCTION

The deformities that we can observe of the cleft lip and palate are among the most common congenital anomalies of the face and palate. (1)

Cleft lip and / or cleft palate (CLP) is a more common or frequent congenital craniofacial anomaly, with a prevalence of 9.92 per 10,000 live births in Italy. The treatment for this anomaly requires multidisciplinary treatments in which there must be a correct communication between: maxillofacial surgeons, orthodontists, oral surgeons, prosthodontists, otorhinolaryngologists, speech and language pathologists, neurologists and psychologists are involved. (2)

The most important for a functional restoration of the masticatory system is the surgical closure of the cleft lip and palate. To achieve success, early reconstruction of a normal anatomy is necessary to allow the normal and physiological growth of the structures of the middle third of the face and allow children to develop unaltered chewing, speech, hearing and aesthetics and, therefore, qualities psychological and social (3)

The treatment of patients with cleft palate depends on the severity of the cleft, as well as early correction of this anomaly. The types of bone graft with cortical and cancellous bone taken from the ilium are recognized as the most effective for closing oronasal communication. After closure, patients with cleft palate often have missing teeth, often including the lateral incisor.

The use of dental implants placed on the grafted alveolar ridge is accepted as a viable method for dental reconstruction. (4)

CASE REPORT

A 33-year-old patient with good health status does not report any illness. He attended the Periodontics Postgraduate Clinic of the School of Dentistry of the Central University of Ecuador, with the purpose of the consultation: “I want to fix my teeth, because I do not like my smile “prior to the clinical examination, we had the informed consent of the patient for the registration of the present case. Once the patient went through the graduate program of Periodontics, he was referred to the Rehabilitation Program of the same institution, since he did not feel well with his teeth. Previously, he was sent to take panoramic and periapical radiographs (Fig.1 A), after which we proceeded to take intra (Fig.1 B) and extra oral photographs (Fig.2)

Fig. 1 A

Fig. 1 B

Fig. 2

Once obtained that, we focused on the taking of impressions to later obtain the models of studies that would be mounted in the Articulator and then make the waxing with its respective planning on implants.

The first surgery consisted in the placement of connective tissue that was obtained from the palate of the patient (Fig. 3 A – B) then this same tissue was placed in the sector of the anterior superior teeth.

Fig. 3 A

Fig. 3 B

After the first surgery a month and a half weeks ago, the incisors were removed, and within a week of performing this procedure, a provisional Acrylic (tooth color) was made in order to give the patient some aesthetics, it must be emphasized that the provisional was left without contact with the tissue. (Fig. 4)

Fig. 4

After 5 months, a second surgery was performed, which consisted in the placement of 2 implants (Mis – Israel) of 3.75 x 10 mm internal hexagon, (Fig. 5) which at the platform level were filled with bone particulate (Bioinnovation – Brazil) because it presented a slight space between socket and implant. (Fig. 5) It was also left with provisional to the second week of surgery without contact with soft tissue.

Fig. 5

In the seventh month of having performed the placement of the implants, a third surgery of connective tissue placement was performed, due to the fact that there was a resorption, for this the connective tissue that was placed where the defect was located was removed from the patient’s palate (Fig. 6 and 7).

Fig. 6

Fig. 7

From the eighth month we proceeded to carve the pieces 13, 23, and 24 and to make impression of the implants for this we use angulated attachments (multiunit) the same that allowed us to correct the inclination of the implants, then the laboratory sent a test in acrylic resin (duralay) the same that allowed to verify a correct settlement of the structure together with this test was sent 3 crowns of lithium discilicate (E max) which were tested in parts 13, 23, 24 (Fig. .8). Then the duralay structure was cast by the laboratory technician (Fig. 9) to perform once again the settlement of the metal structure. (5)

Fig. 8

Fig. 9

Once the tests were done, they were sent to the laboratory so that they could finish the work. After that, the crowns were cemented and the ceramic metal structure was screwed on implants (Fig. 10), then panoramic and periapical radiographs were taken. to observe the correct settlement of the structure on implants and crowns. (Fig. 11 A – B).

Fig. 10

Fig. 11 A

Fig. 11 B

At the end of the patient’s treatment, it is recommended to use a stabilization splint so that there is no overload problem in the lower parts (Fig. 12).

Fig. 12

After the treatment, the photographs were taken and the patient was treated before and after the treatment.

Patient lips at rest a better disposition of the lips is observed (Fig. 13 A – B)

Fig. 13 A

Fig. 13 B

Patient in smile shows a curvature of his broad smile according to his facial profile (Fig. 14 A – B).

Fig. 14 A

Fig. 14 B

In a profile picture, one can see the patient’s lips at rest (Fig. 15) and another image of the patient’s smile in profile (Fig. 16).

Fig. 15

Fig. 16

Another intra-oral image of the patient can be seen before and after the treatment (Fig. 17)

Fig. 17

Finally an occlusal view of the patient’s upper arch before and after it (Fig. 18).

Fig. 18

DISCUSSION

The literature tells us of a good prognosis when using implants in patients with cleft palate, likewise the survival rate according to Gomes indicates that it is 95% during the first 5 years all this will depend on the care of the patient and the patient’s hygiene as referred to Papi P in 2015. 1,2

In the present article, the patient’s own connective tissue graft was placed, at the same time, bovine xenoingetum, obtaining good results, based on the article by N. Niez (6) which indicates that the degree of resorption of the bone grafts. it is 3.5% horizontally and 2.7% vertically. Another author Russell (7) reports that graft after surgery has many reported benefits, including periodontal support for teeth adjacent to the cleft, this provides a correct disposition of the tissues when planning some type of rehabilitation. 6.7.

Subsequent to the placement of the grafts, we proceeded to the placement of the implants, which had a torque of 35 N, which is considered a correct primary stabilization. The use of dental implants as an alternative in this type of patients has a good prognosis. This is what Vecchiatini R 4 refers to, which indicates that implants have many advantages: they provide good support for the dental prosthesis, an excellent aesthetic result, the preservation of healthy adjacent teeth and the prevention of resorption of the grafted bone. 4

Those patients who were treated with xenoinjects showed good stability during the first 7 years with a success rate of 88 to 93% according to Mônica Diuana (8)

In the dental pieces lithium discilicate crowns were made in that this material has good compatibility in the functional and aesthetic aspect of the patient, also because of the age of the same this treatment was ideal, this agrees with Toman (9) in a study In vivo 9-year follow-up which concluded that the survival rate of this type of material is 87.1%. 9

CONCLUSIONS

With this type of multidisciplinary treatment the aesthetic and functional part will be improved, but above all the quality of life of the patients with cleft palate.