Conventional prosthodontic management

of partial edentulism with a resilient

attachment-retained overdenture in a
patient with a cleft lip and palate:
A clinical report
Varun Acharya, BDSa and Lawrence E. Brecht, DDSb
The University of Texas MD Anderson Cancer Center, Houston, Texas;
New York University College of Dentistry, New York, NY
Recent advances in surgery and orthodontics have resulted in improvements in the management of patients with a cleft lip
or palate. Early surgical intervention and bone-grafting procedures have frequently been used to ensure closure of the
cleft and continuity of the alveolar bone. However, a need for the prosthodontic management of patients with a cleft palate
still exists. Most frequently, the indication is to restore the edentulous spaces located anteriorly in the vicinity of the
residual cleft defect. In addition to improving the esthetic outcome, prosthodontic management also is required to restore
function, especially occlusion and speech. This clinical report illustrates the management of an adult patient with a unilateral
cleft of the lip and palate who required prosthodontic rehabilitation after surgery. The patient had previously undergone
multiple surgeries and did not want to consider implant therapy as a treatment option. Thus, the patient was managed
with fixed and removable prosthodontics with a maxillary overdenture prosthesis retained by microextracoronal resilient
attachments, which were laser welded onto crowns on abutment teeth to obtain a functionally and esthetically acceptable
result. (J Prosthet Dent 2014;-:---)

The management of patients with a
cleft lip and palate poses a significant
challenge to the medical and dental
professions. Besides the technical chal-
lenge involved, these patients also have
significant psychosocial difficulties.1
Early intervention and recent improve-
ments in surgical and orthodontic
procedures have decreased the need for
prosthodontic management of patients
with a cleft lip and palate.2 Yet, pros-
thodontic intervention is frequently
required for patients who have had or-
thodontic and surgical treatment.3,4
Patients who have not received surgi-
cal or orthodontic care early in life
are the most challenging patients to
manage prosthetically later in life.5
Bone grafting procedures required to
close the alveolar cleft may not be
successful in this population because of
the volume of the bone graft required.
In such patients, implant therapy will
not be an option in the region of the
cleft because of the lack of available
bone.6 Other challenges for successful
placement of dental implants in this
patient population include the chal-
lenging contour of the labial cortical
plate, the quality of the bone, and the
proximity to the nasal cavity and
maxillary sinus.7
By the time they become teenagers
and young adults,1 many patients with
a cleft lip and palate have already un-
dergone extensive surgical procedures
and may not be receptive to the idea
of more surgery to place dental im-
plants. In such patients, a fixed dental
prosthesis (FDP) may be indicated
to rehabilitate the patient.8-10 Besides
replacing the missing teeth, the FDP
may stabilize mobile premaxillary seg-
ments and restore arch integrity.6,8,9
However, in certain patients, the vol-
ume of soft and hard tissue lost as a
result of this congenital defect is so
significant that restoration with a con-
ventional FDP may not provide the best
result. The 3-dimensional nature of the
cleft defect produces both soft- and
hard-tissue deficiencies. The remaining
abutment teeth may provide a solid
foundation for the fabrication of
crowns that can provide retention
for a tooth-supported overdenture. This
tooth-supported overdenture can serve
to rehabilitate the dentition because it
has good retention from the underlying
abutment teeth and may also provide
acceptable esthetics and function.
The authors identified no previous re-
ports of the management of a cleft lip
and palate with a microextracoronal
resilient attachment retained tooth-
supported overdenture, and the pur-
pose of this report is to highlight one
such treatment.
CLINICAL REPORT
A 55-year-old South American
woman presented to the New York
University College of Dentistry’s pre-
doctoral clinic and was referred to
the postgraduate prosthodontic clinic
because of the complexity of care
required. The patient was a language
teacher by profession, had no history of
tobacco use, and reported only social

a
Fellow, Department of Head and Neck Surgery, Section of Oral Oncology and Maxillofacial Prosthodontics, The University of Texas
MD Anderson Cancer Center.
b
Clinical Associate Professor, Jonathan and Maxine Ferencz Advanced Education Program In Prosthodontics, NYU College of Dentistry;
Clinical Assistant Professor of Plastic Surgery, Institute of Reconstructive Plastic Surgery, NYU Langone Medical Center.

Acharya and Brecht

2 Volume - Issue -

1 Initial presentation in maximum intercuspation. 2 Intraoral view of maximum intercuspation without existing
maxillary overdenture.

3 Occlusal view of existing maxillary restorations. 4 Smile without existing overdenture.

use of alcohol. She admitted to drink-
ing multiple cups of strong coffee
every day and believed that this
contributed significantly to the stains
on her teeth. The patient had a history
of a right-sided unilateral cleft of her
lip, alveolus, and hard palate. She had
a significant surgical history for the
management of her cleft lip and palate.
She had undergone an initial surgery
when she was 2 days old and then
additional procedures at 2, 5, 11, 18,
20, and 24 years of age. When she was
15 years old, her dentist advised the
removal of her maxillary anterior teeth
and rehabilitated her prosthetically with
a maxillary overdenture. When she was
47 years old, a fistula developed in
her palate that was surgically closed
by a plastic surgeon. She had multiple
conventional dental procedures on
The Journal of Prosthetic Dentistry
her mandibular dentition, including
amalgam, composite resin, and com-
plete coverage restorations.
The patient had a partially edentu-
lous maxilla with 8 remaining teeth
(maxillary first molar, maxillary second
premolar, maxillary first premolar, and
maxillary canine on both left and right
sides), most of which had metal partial
or complete coverage restorations.
Endodontic treatment was previously
completed on the right first maxillary
molar, right second maxillary premolar,
right maxillary canine, left maxillary first
premolar, left maxillary second premo-
lar, and left maxillary first molar. Posts
and cores were present on right first
maxillary molar, right second maxillary
premolar, right maxillary canine, left
second maxillary premolar and left
first maxillary molar. The remaining
natural teeth supported an overdenture
(Figs. 1, 2). The prognosis for her
remaining maxillary teeth was good
because these teeth showed no evidence
of periodontal disease or periapical
pathology.11 The complete coverage
restorations all showed clinical signs
of deterioration (Fig. 3) and her lip
was inadequately supported without
the overdenture in place (Fig. 4). The
maxillary overdenture displayed signifi-
cant occlusal wear, had fractured
clasps and surface staining, and had
poor retention that interfered with her
speech. She did not have any nasal
regurgitation of liquids or food when
the overdenture was not in place,
which suggests sufficient closure of the
hard palate and alveolus defect. Her
mandible was also partially edentulous,
and had been restored with complete
Acharya and Brecht
- 2014
5 Artificial tooth arrangement indexed with condensation
silicone.
coverage restorations amalgam and
composite resin restorations.
Preliminary impressions were made
with irreversible hydrocolloid impression
material (Jeltrate; Dentsply Intl), and the
benefits and risks of treatment were
explained to the patient at the initial
diagnostic visit. The potential cost of
treatment was a cause for concern, and
she desired to use her resources to
restore her maxillary dentition at New
York University College of Dentistry
and then to address the issues in her
mandibular dentition in her home
country. She also requested that surgical
procedures, including implants, be
avoided if possible because of her
extensive surgical history and resulting
psychologic stress. A treatment plan
was developed to replace the existing
complete coverage restorations in her
maxilla. A new tooth-supported over-
denture was planned to restore the form,
function, and esthetics of the maxillary
arch.
The existing maxillary complete
and partial coverage restorations were
removed. The crown preparations on
the maxillary teeth were suitably
refined, and interim restorations were
made with a chairside interim resin
(Alike; GC America) from a matrix
obtained from the preliminary casts.
The intaglio surface of the existing
overdenture was hollowed out and
relined with tissue-conditioning mate-
rial (Coe-Comfort; GC America) after
the interim restorations had been
Acharya and Brecht
6 Buccal index of artificial tooth arrangement in place;
volume of deficient hard and soft tissue is evident.
lubricated with petroleum jelly (Vase-
line; Unilever).
After necessary endodontic treat-
ment was completed and cast posts
and cores fabricated from Type IV
gold (Callisto Implant 60; Ivoclar
Vivadent) were cemented, a definitive
impression was made with polyether
impression material (Impregum; 3M
ESPE) in 2 separate impressions. Max-
illomandibular relation records were
obtained with a fast-setting occlusal
registration material (Blu-Bite; Henry
Schein). A record base was fabricated,
and an artificial tooth arrangement was
made with cross-linked resin teeth
(Portrait IPN; Dentsply Intl). The patient
expressed her satisfaction with the es-
thetics and phonetics of the artificial
tooth arrangement. Nonanatomic metal
copings were fabricated from a high
noble alloy (Callisto Implant 60; Ivoclar
Vivadent) by using a condensation sili-
cone index (Lab-Putty; Coltène/Whale-
dent) of the artificial tooth arrangement
as a guide (Figs. 5, 6). These copings
provided an appropriate path of place-
ment for the overdenture.
Microextracoronal resilient attach-
ments (Sterngold Dental) were laser
welded onto the occlusal surface of
the crowns of 4 strategic teeth, whereas
the remaining 4 teeth acted as vertical
stops for the overdenture. The metal
complete coverage restorations were
cemented with resin modified glass
ionomer cement (FujiCEM; GC Amer-
ica) (Fig. 7). The maxillary overdenture
3
metal framework (Wironit; Bego) was
fabricated by using the silicone index
of the artificial tooth arrangement as
a guide and was evaluated intraorally
to confirm appropriate fit. The artificial
tooth arrangement was transferred
to the metal framework and a second
evaluation was completed. The over-
denture was processed in heat-
polymerized injection-molded denture
base resin (SR Ivocap High Impact;
Ivoclar Vivadent), and space was pro-
vided to facilitate transfer of the resil-
ient attachment (microextracoronal
resilient attachments; Sterngold Dental)
housings into the overdenture with
chemically polymerized acrylic resin
(TruRepair; The Harry J. Bosworth Co).
The overdenture was polished and
inserted, with conventional instructions
provided to the patient.12 During the
follow-up appointment, the black pro-
cessing liners (Fig. 8) of the resilient
attachments (Sterngold Dental) were
replaced with white liners that provided
sufficient retention. The mandibular
dentition was then addressed. A
posterior mandibular FDP (Callisto
Implant 60 and IPS d.SIGN; Ivoclar
Vivadent) on the right side was fabri-
cated with conventional techniques. For
financial reasons, the patient elected to
have the left side of her mandible
(including endodontic therapy) treated
in her home country.
At the conclusion of treatment,
the patient expressed her satisfaction
with the outcome of her prosthetic
4 Volume
7 Cemented individual copings with laser-welded resilient
attachments on selected teeth. Remaining teeth act as
positive stops for overdenture.
9 Frontal view of completed treatment.
rehabilitation and was pleased with
the form, function, and esthetics of
her new smile (Figs. 9, 10). Home
care instructions, including regular
flossing and the use of fluoridated
toothpaste, were discussed with the
patient. She also was informed of
the need to replace the liners of the
resilient attachments with frequent
use. She was followed up for 2 months
after completion of treatment and is
on regular oral hygiene recall visits
every 6 months. The overdenture is
potentially salvageable if a failure of
1 abutment tooth retaining a resilient
attachment does occur. However,
the failure of more than 1 abutment
tooth retaining a resilient attach-
ment can severely compromise the
overdenture.
The Journal of Prosthetic Dentistry
8 Intaglio surface of processed maxillary overdenture. Black
processing liners were changed to white retentive liners 1 week
after insertion.
10 Profile view of completed treatment.
SUMMARY
The management of a patient with
cleft lip, alveolus, and palate with
conventional prosthodontic treatment
has been illustrated. When the volume
of tissue to be replaced prosthetically
is extensive, an overdenture on the
remaining natural teeth can provide
a highly successful functional and
esthetic result.
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Acharya and Brecht
5
12. Felton D, Cooper L, Duqum I, Minsley G, Acknowledgment
Guckes A, Haug S, et al. Evidence-based The authors thank Mr Steven Pigliacelli of
guidelines for the care and maintenance Marotta Dental Studio for his technical
of complete dentures: a publication of expertise.
the American College of Prosthodontists.
J Am Dent Assoc 2011;142(suppl 1):1S-20S. Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Corresponding author:
Dr Varun Acharya
The University of Texas MD Anderson Cancer
Center
1515 Holcombe Blvd
Houston, TX 77030
E-mail: varun.acharya@gmail.com