CHIEF COMPLAINT:
Bad esthetics and insufficient function of the anterior upper teeth due to a surgical correction of a labial and palatal cleft.
DIAGNOSIS:
Female patient, 20 years old, non-smoker, had several surgical interventions to correct labial and palatal cleft. Patient presented a significant edentulous area between teeth 13 and 11, also due to the absence of teeth 12 and 15. Due to a traumatic impact, tooth 11 was non-vital, and extensively reconstructed with composite. Patient also had an orthodontic appliance with two prosthetic teeth and a buccal arch in this area to avoid teeth movement in this area. The area of the surgical correction of the labial and palatal cleft presented a significant deformity of hard and soft-tissues.
TREATMENT PLAN:
Root canal treatment was immediately performed on tooth 11. In the meanwhile, a CBCT scan was done to evaluate bone quality and quantity in the cleft area. The available bone was significantly reduced in vertical and horizontal dimensions. Due to the difficulty in performing a bone augmentation in this area, together with periodontal surgery to improve soft tissues, our treatment plan was the following:
Fixed partial denture between teeth 15 and 11, using teeth 14, 13 and 11 as abutments. Teeth 12 and 15 were planned as ovoid pontics. The framework material chosen was zirconia and the veneering ceramics should have a gum-shade component to rehabilitate the soft-tissues.
TEAM PLAY ‘DENTIST – DENTAL TECHNICIAN’ NOTES:
In the esthetic rehabilitation of cleft patients, we should study how to restore the symmetry of the dental arch and then how to compensate the soft tissue deformity keeping the same symmetry. In that sense, the provisional bridge made in the dental lab follow that approach. First we looked for the symmetry of the dental arch, with the production of provisional teeth similar to the natural homologous, and then an acrylic gum-shade component was included with the aim to rehabilitate the deformity of the cleft area. A metallic reinforcement was included in the provisional bridge, and the teeth preparations in the model were minimal invasive and guided by the Dentist. The working model was obtained through a dental impression, double-mix technique. In the dental lab, the CAD-CAM technology was used to produce a zirconia framework. In the provisional bridge, it was noted by the patient, and by ourselves, the need for symmetry in the dimensions and shape of the teeth, in relation to their homologues of the 2nd quadrant. Accordingly, a mirror effect was selected in the CAD design of the framework, to mimic in the prosthetic structure the dimensions and shape of the homologous natural teeth. Framework design included also a small zirconia wing covering the palatal surface of the non-prep tooth 21. This wing serves as an additional support and, simultaneously, avoids an eventual occurrence of a future diastema between central incisors. Color selection of teeth and soft-tissues was done by the ceramist in the dental office. After evaluation and approval of the prosthetic work placed in mouth, the dental bridge was bonded. This bonding procedure was optimized by the addition of a zirconia liner in the inner surface of the framework and in the internal surface of the wing. This treatment proved to be esthetically acceptable and functionally able, with a strong contribution to the patient’s self-esteem.