Alternatives for rehabilitation of cleft patients with severe maxillomandibular discrepancy.

Rehabilitation of cleft patients is a process that occurs from birth to adult life and involves a team of many professionals. Reconstructive plastic surgery, despite its functional and aesthetic benefits to the patient, can restrict the normal anterior displacement that occurs in the growth of the maxilla, which, in turn, can lead to a concave profile that requires correction. This study aimed to demonstrate an alternative rehabilitation treatment for cleft patients who have severe maxillomandibular discrepancy and choose not to undergo orthognathic surgery. A retrospective review and case reports of rehabilitation treatment of cleft patients were performed, with an emphasis on prosthetic rehabilitation without orthognathic surgical procedures. Prosthetic rehabilitation is a fast and reversible option for cleft patients that provides facial harmony and facilitates the reintegration of these patients into society.

Cleft palate obturation with Brånemark protocol implant-supported fixed denture and removable obturator.

A 41-year-old man with cleft palate presented with a wide dehiscence and missing teeth. Six implants had been placed for fabrication of an overdenture, which was unsatisfactory. A bar was waxed and cast for connection to the implants; precision attachments were placed laterally for retention. A fixed partial denture was fabricated, and milled crowns were fabricated at the molar region to provide a guiding plane for insertion of a removable palatal obturator. Good swallowing and speech outcomes were achieved. This technique provided functional and esthetic benefits, enhanced oral hygiene, and improved the psychological condition of the patient.

Interrelationship between implant and orthognathic surgery for the rehabilitation of edentulous cleft palate patients: a case report.

A 43-year-old woman with a unilateral cleft lip and palate, presenting a totally edentulous maxilla and mandible with marked maxillomandibular discrepancy, attended the Prosthodontics section of the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo for treatment. She could not close her mouth and was dissatisfied with her complete dentures. Treatment planning comprised placement of six implants in the maxilla, four in the mandible followed by prostheses installation and orthognathic surgery. The mandibular full arch prosthesis guided the occlusion for orthognathic positioning of the maxilla. The maxillary complete prosthesis was designed to assist the orthognathic surgery with a provisional prosthesis (no metal framework), allowing reverse treatment planning. Maxillary and mandibular realignment was performed. Three months later, a relapse in the position of the maxilla was observed, which was offset with a new maxillary prosthesis. This isa complex interdisciplinary treatment and two-year follow-up is presented and discussed. It should be considered that this type of treatment could also be applied in non-cleft patients.

Evaluation of shear bond strength of composite to porcelain according to surface treatment.

This study evaluated the shear bond strength of porcelain/composite using 40 metal + porcelain + composite cylindrical specimens divided into 4 groups, according to porcelain surface treatment: 1) no treatment, 2) mechanical retentions performed with diamond burs, 3) etching with phosphoric acid+silane, and 4) etching with hydrofluoric acid+silane. After being stored in distilled water at room temperature for one week, the specimens were submitted to a shear force (load) and the data were analyzed statistically (ANOVA). The means (in Mpa) of the groups were: 4.71 (group 1); 4.81 (group 2); 11.76 (group 3); 11.07 (group 4). There were no statistically significant differences between groups 1 and 2 and between groups 3 and 4.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 4: oral rehabilitation.

Treatment of patients with cleft lip and palate is completed with fixed prostheses, removable, total, implants and aims to restore aesthetics, phonetics and function and should be guided by the basic principles of oral rehabilitation, such as physiology, stability, aesthetics, hygiene and the expectations of the patient. In order to obtain longevity of a prosthetic rehabilitation, the periodontal and dental tissue as well as the biomechanics of the prosthesis are to be respected. The purpose of this article is to describe the types of prosthetics treatment, which are performed at HRAC/USP for the rehabilitation of cleft area in adult patients.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 5: institutional outcomes assessment and the role of the Laboratory of Physiology.

The Laboratory of Physiology provides support for the diagnosis of functional disorders associated with cleft lip and palate and also conducts studies to assess, objectively, the institutional outcomes, as recommended by the World Health Organization. The Laboratory is conceptually divided into three units, namely the Unit for Upper Airway Studies, Unit for Stomatognathic System Studies and the Unit for Sleep Studies, which aims at analyzing the impact of different surgical and dental procedures on the upper airways, stomatognathic system and the quality of sleep of individuals with cleft lip and palate. This paper describes the main goals of the Laboratory in the assessment of procedures which constitute the basis of the rehabilitation of cleft lip and palate, i.e., Plastic Surgery, Orthodontics and Maxillofacial Surgery and Speech Pathology.

Impact of Cleft Lip and Palate on Oral Health-Related Quality of Life (OHRQOL) in Brazilian Patients

Objective: To evaluate self-esteem, satisfaction with facial aesthetics and the impact of oral health on the quality of life of patients with cleft lip and palate aged from 12 years treated at the Hospital for Rehabilitation of Craniofacial Anomalies (HRAC), Brazil. Material and Methods: A cross-sectional study was conducted with patients (n=94) with cleft lip and palate, aged 12 years and older, treated at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Brazil. The instruments used in this study were: Rosenberg's Self-Esteem Scale, the Oral Health Impact Profile-14 (OHIP), and a visual analogue scale of self-perceived facial aesthetics were applied, and socioeconomic and contextual data were collected from all patients. The statistical analysis included Poisson regression with robust variance (RR ­ rate ratio) and it was performed to evaluate the association between predictors and the outcome oral health related-quality of life. Results: Worse OHRQoL was reported by female patients (RR 1.21; 95%CI: 1.09-1.35) and older individuals (RR 1.25; 95%CI:1.13- 1.39). Conclusion: The presence of cleft lip and palate has a negative impact on OHRQoL. Females and older individuals reported worse qualify of life.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies-USP (HRAC-USP)--part 2: pediatric dentistry and orthodontics.

The aim of this article is to present the pediatric dentistry and orthodontic treatment protocol of rehabilitation of cleft lip and palate patients performed at the Hospital for Rehabilitation of Craniofacial Anomalies-University of São Paulo (HRAC-USP). Pediatric dentistry provides oral health information and should be able to follow the child with cleft lip and palate since the first months of life until establishment of the mixed dentition, craniofacial growth and dentition development. Orthodontic intervention starts in the mixed dentition, at 8-9 years of age, for preparing the maxillary arch for secondary bone graft procedure (SBGP). At this stage, rapid maxillary expansion is performed and a fixed palatal retainer is delivered before SBGP. When the permanent dentition is completed, comprehensive orthodontic treatment is initiated aiming tooth alignment and space closure. Maxillary permanent canines are commonly moved mesially in order to substitute absent maxillary lateral incisors. Patients with complete cleft lip and palate and poor midface growth will require orthognatic surgery for reaching adequate anteroposterior interarch relationship and good facial esthetics.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies-USP (HRAC-USP)--part 3: oral and maxillofacial surgery.

This paper presents the treatment protocol of maxillofacial surgery in the rehabilitation process of cleft lip and palate patients adopted at HRAC-USP. Maxillofacial surgeons are responsible for the accomplishment of two main procedures, alveolar bone graft surgery and orthognathic surgery. The primary objective of alveolar bone graft is to provide bone tissue for the cleft site and then allow orthodontic movements for the establishment of an an adequate occlusion. When performed before the eruption of the maxillary permanent canine, it presents high rates of success. Orthognathic surgery aims at correcting maxillomandibular discrepancies, especially anteroposterior maxillary deficiencies, commonly observed in cleft lip and palate patients, for the achievement of a functional occlusion combined with a balanced face.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP)--Part 1: overall aspects.

Cleft lip and palate is the most common among craniofacial malformations and causes several esthetic and functional implications that require rehabilitation. This paper aims to generally describe the several aspects related to this complex pathology and the treatment protocol used by the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC-USP) along 40 years of experience in the treatment of individuals with cleft lip and palate.

Interrelationship between implant and orthognathic surgery for the rehabilitation of edentulous cleft palate patients: a case report

A 43-year-old woman with a unilateral cleft lip and palate, presenting a totally edentulous maxilla and mandible with marked maxillomandibular discrepancy, attended the Prosthodontics section of the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo for treatment. She could not close her mouth and was dissatisfied with her complete dentures. Treatment planning comprised placement of six implants in the maxilla, four in the mandible followed by prostheses installation and orthognathic surgery. The mandibular full arch prosthesis guided the occlusion for orthognathic positioning of the maxilla. The maxillary complete prosthesis was designed to assist the orthognathic surgery with a provisional prosthesis (no metal framework), allowing reverse treatment planning. Maxillary and mandibular realignment was performed. Three months later, a relapse in the position of the maxilla was observed, which was offset with a new maxillary prosthesis. This isa complex interdisciplinary treatment and two-year follow-up is presented and discussed. It should be considered that this type of treatment could also be applied in non-cleft patients.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) Part 4: Oral Rehabilitation

Treatment of patients with cleft lip and palate is completed with fixed prostheses, removable, total, implants and aims to restore aesthetics, phonetics and function and should be guided by the basic principles of oral rehabilitation, such as physiology, stability, aesthetics, hygiene and the expectations of the patient. In order to obtain longevity of a prosthetic rehabilitation, the periodontal and dental tissue as well as the biomechanics of the prosthesis are to be respected. The purpose of this article is to describe the types of prosthetics treatment, which are performed at HRAC/USP for the rehabilitation of cleft area in adult patients.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 5: Institutional outcomes assessment and the role of the Laboratory of Physiology

The Laboratory of Physiology provides support for the diagnosis of functional disorders associated with cleft lip and palate and also conducts studies to assess, objectively, the institutional outcomes, as recommended by the World Health Organization. The Laboratory is conceptually divided into three units, namely the Unit for Upper Airway Studies, Unit for Stomatognathic System Studies and the Unit for Sleep Studies, which aims at analyzing the impact of different surgical and dental procedures on the upper airways, stomatognathic system and the quality of sleep of individuals with cleft lip and palate. This paper describes the main goals of the Laboratory in the assessment of procedures which constitute the basis of the rehabilitation of cleft lip and palate, i.e., Plastic Surgery, Orthodontics and Maxillofacial Surgery and Speech Pathology.

Speech intelligibility of patients with cleft lip and palate after placement of speech prosthesis.

OBJECTIVE: To evaluate the speech intelligibility of patients with clefts before and after placement of a speech prosthesis. DESIGN: Cross-sectional. SETTING: Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC/USP), Bauru, Brazil. PATIENTS: Twenty-seven patients with unoperated cleft palate or operated cleft palate presenting with velopharyngeal insufficiency (VPI) after primary palatoplasty, treated with speech prosthesis, aged 8 to 63 years. INTERVENTIONS: Patients were fitted with palatopharyngeal obturators or pharyngeal bulbs, suitable to their dental needs. Five speech-language pathologists blindly evaluated speech samples of the patients with and without the prosthesis. MAIN OUTCOME MEASURES: Classification of speech samples according to a scoring system developed for speech intelligibility problems: 1 (normal), 2 (mild), 3 (mild to moderate), 4 (moderate), 5 (moderate to severe), and 6 (severe). Results were evaluated by the calculation of means of all judges for each patient in both situations. RESULTS: The judges presented significant agreement (W=.789, p<.01). Speech intelligibility was significantly better after placement of the prosthesis for both unoperated patients (Z=1.93, p=.02) and operated patients with VPI after primary palatoplasty (Z=1.78, p=.03). CONCLUSIONS: Speech intelligibility may be improved by rehabilitation of patients with cleft palate using a speech prosthesis. Speech therapy is needed to eliminate any compensatory articulation productions developed prior to prosthetic management.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 1: overall aspects

Cleft lip and palate is the most common among craniofacial malformations and causes several esthetic and functional implications that require rehabilitation. This paper aims to generally describe the several aspects related to this complex pathology and the treatment protocol used by the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC-USP) along 40 years of experience in the treatment of individuals with cleft lip and palate.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC-USP) - Part 2: Pediatric Dentistry and Orthodontics

The aim of this article is to present the pediatric dentistry and orthodontic treatment protocol of rehabilitation of cleft lip and palate patients performed at the Hospital for Rehabilitation of Craniofacial Anomalies - University of São Paulo (HRAC-USP). Pediatric dentistry provides oral health information and should be able to follow the child with cleft lip and palate since the first months of life until establishment of the mixed dentition, craniofacial growth and dentition development. Orthodontic intervention starts in the mixed dentition, at 8-9 years of age, for preparing the maxillary arch for secondary bone graft procedure (SBGP). At this stage, rapid maxillary expansion is performed and a fixed palatal retainer is delivered before SBGP. When the permanent dentition is completed, comprehensive orthodontic treatment is initiated aiming tooth alignment and space closure. Maxillary permanent canines are commonly moved mesially in order to substitute absent maxillary lateral incisors. Patients with complete cleft lip and palate and poor midface growth will require orthognatic surgery for reaching adequate anteroposterior interarch relationship and good facial esthetics.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC-USP) - part 3: Oral and Maxillofacial Surgery

This paper presents the treatment protocol of maxillofacial surgery in the rehabilitation process of cleft lip and palate patients adopted at HRAC-USP. Maxillofacial surgeons are responsible for the accomplishment of two main procedures, alveolar bone graft surgery and orthognathic surgery. The primary objective of alveolar bone graft is to provide bone tissue for the cleft site and then allow orthodontic movements for the establishment of an an adequate occlusion. When performed before the eruption of the maxillary permanent canine, it presents high rates of success. Orthognathic surgery aims at correcting maxillomandibular discrepancies, especially anteroposterior maxillary deficiencies, commonly observed in cleft lip and palate patients, for the achievement of a functional occlusion combined with a balanced face.

Pattern of disocclusion in patients with complete cleft lip and palate.

OBJECTIVE: To analyze the pattern of disocclusion during excursive mandibular movements and presence or absence of occlusal interferences and occlusal pathologies (gingival recession and abfraction). METHOD: Examination of 120 individuals divided into two groups, as follows: Group 1 - 90 patients with complete cleft lip and palate (study group), subdivided into 30 patients with complete left unilateral cleft lip and palate, 30 patients with complete right unilateral cleft lip and palate and 30 patients with complete bilateral cleft lip and palate; Group 2 - 30 individuals without clefts (control group). RESULTS: 58.8% of patients in Group 1 presented unilateral or bilateral canine guidance, 26.6% presented unilateral or bilateral group function and 54.4% presented lateral movements through the posterior teeth. Regarding protrusive movements, 80% presented anterior guidance and 20% presented posterior guidance. In Group 2, 69.6% of individuals presented unilateral or bilateral canine guidance, 43.2% presented unilateral or bilateral group function and only 13.3% presented lateral movements through the posterior teeth; 3.4% presented protrusion through the posterior teeth. CONCLUSIONS: There was no difference in the pattern of disocclusion between subgroups of patients with clefts. Group 2 presented predominance of bilateral group function, whereas Group 1 presented a higher prevalence of posterior guidance during lateral movements. Protrusion occurred primarily through anterior guidance in Group 2 and through the posterior teeth in Group 1. There was high prevalence of occlusal interferences at the molar area for both groups, yet with no correlation with occlusal pathologies (recession and abfraction).

Efeito de diferentes elastômeros na adaptação cervical de coroas totais metálicas / Effect of different elastomers on cervical fit of full metal crowns

Objective: The aim of this study was to evaluate the cervical fit of full metal crowns using four different elastomers. Methods: A stainless steel metallic die similar to a prepared first upper molar was obtained. Four di-fferent elastomeric impression materials were utilized: polysulfide (A), polyether (B), condensation silicone (C) and addition silicone (D). Forty molds were created, 10 for each group. It was obtained 40 gypsum abutments. After the end of this stage, it was performed complete metal crowns on all specimens. Crown displacement was measured through a comparative microscope, obtaining diametrically opposite points. Results: The re-sults were the following: Group D (31.97 um), Group B (49.57 um), Group A (51.12 um), Group C (61.12 um). The analysis of variance (ANOVA) test and a Tukey test for multiple comparisons were used to analyze the results. Conclusions: There were significant differences among all groups, except for Groups A and B. The major result of displacement was Group C. The best results were shown by Group D (p < 0.05).

Evaluation of palatal prosthesis for the treatment of velopharyngeal dysfunction.

Some patients presenting velopharyngeal dysfunction need treatment with a palatal prosthesis, and few researches attempt to evaluate the judgement of its efficacy. For that reason, a questionnaire was submitted to 48 patients with a palatal prosthesis, with ages from 8 to 74 (mean 31.47), from which 42 had a congenital cleft, 2 exhibited an acquired cleft and 4 presented total or partial palsy of the soft palate. Results reveled that 81.2% of these patients were able to eat while using their prostheses; 85.4% stated their speech had improved with the prostheses; 75% considered the prosthesis stable during nourishment, and 91.7% during speech; 79.2% felt comfortable using the prosthesis; and 85.4% related a general improvement in life quality with the prosthetic treatment of velopharyngeal dysfunction. It was concluded that the prosthetic treatment of velopharyngeal dysfunction demonstrated efficacy in improving speech, despite of the heterogeneous sample. Besides, it offered the other basic requirements of a prosthesis whenever it was needed.