Removable partial denture with attachment as a treatment option in patients with cleft lip and palate / Prótese parcial removível com encaixe como opção de tratamento em paciente com fissura labiopalatina

ABSTRACT The rehabilitation treatment of patients with cleft lip and palate is lengthy and is carried out by various professionals from different areas of healthcare.To this end, planning and specialist knowledge are critical to the success of the treatment, in this way envisioning the aesthetic and functional rehabilitation of the individual in order to integrate them into society. This study consists of a literature review along with the report of a clinical case, demonstrating the treatment performed with the use of a removable partial denture using the abutment teeth treated with milled metal-ceramic crowns and the use of attachments, with a view to promoting the retention and stability of the prosthetic device. With the use of this system as a whole, aimed at improving the facial proportions due to the restoration of vertical dimension of occlusion and adequate lip support, features that are often not present in individuals with cleft lip and palate. In this work, we are seeking to underline the importance of scientific and technical knowledge, combined with a well-executed planning, in order to achieve successful treatment that restores function and aesthetics to the patient, thereby enabling their reintegration into society.

RESUMO O tratamento reabilitador de um paciente com fissura labiopalatina envolve um longo período e efetuado por diversos profissionais de diferentes áreas da saúde. Para tal, o planejamento e o conhecimento específico são de suma importância para o sucesso do tratamento, vislumbrando, dessa forma, a reabilitação estética e funcional do indivíduo de forma a integrá-lo na sociedade. O presente trabalho consiste em relato de um caso clínico, demonstrando o tratamento efetuado com a utilização de prótese parcial removível utilizando os dentes pilares tratados com coroas metalo-cerâmicas fresadas e a utilização de encaixes, com intuito de favorecer a retenção e estabilidade do aparelho protético. Com o uso de todo esse sistema objetivando a melhoria nas proporções faciais devido à devolução da dimensão vertical de oclusão e suporte labial adequado, características que muitas vezes não estão presentes nos indivíduos com fissuras labiopalatinas. Este trabalho tem o intuito de ressaltar a importância do conhecimento científico e técnico, somados a planejamento bem realizado a fim de se conseguir o sucesso do tratamento, devolvendo função e estética do paciente, reintegrando-o a sociedade.

Sobredentaduras maxilares implantossuportadas para pacientes com fissura labiopalatina / Maxillary implant-supported overdentures for patients with cleft lip and palate

Pacientes portadores de fissura labiopalatina possuem alterações anatômicas que dificultam o planejamento e a execução de tratamentos reabilitadores protéticos extensos. As próteses do tipooverdentures são indicadas principalmente diante de casos mais extremos de perdas ósseas, associados a relações maxilomandibulares bastante desfavoráveis. Essas próteses totais implantossuportadas confeccionadas para pacientes portadores de fissura labiopalatina podem possuir algumas alterações e apresentar dificuldades. O objetivo deste artigo é relatar alternativas para a confecção de próteses implantossuportadas no que diz respeito principalmente ao desenho da barra e posicionamento dos componentes de retenção (AU).

Patients with cleft lip and palate have anatomic discrepancies that may impair the appropriate planning and execution of extensive prosthetic treatments. Overdentures are indicated mainly for cases of severe bone resorption, associated with unfavorable antero-posterior maxillary relations. These total implant-supported prostheses for patients with clefts may need some alterations and present some difficulties. The aim of this paper is to report different ways to produce overdentures, specially related to the design of the bars and positioning of the retention components (AU).

Força de mordida em pacientes com fissura labiopalatina reabilitados proteticamente / Bite force in patients with cleft lip and palate with prosthetic rehabilitation

O objetivo deste trabalho foi comparar a força de mordida máxima entre indivíduos sem fissura labiopalatina e com dentes naturais, indivíduos com fissura labiopalatina reabilitados com prótese parcial fixa sobre implante e indivíduos com fissura labiopalatina reabilitados com prótese parcial fixa convencional, principalmente na região de incisivo lateral e canino. Para isso, os sujeitos da pesquisa foram divididos em 2 grupos experimentais: Prótese Parcial Fixa Sobre Implante (n=6) e Prótese Parcial Fixa Convencional (n=10) e grupo Controle (n=11). As medidas de força de mordida foram realizadas com um gnatodinamômetro, sendo então analisadas estatisticamente por meio do teste de Kruskal-Wallis com nível de significância de 0,05. Quando verificada significância estatística, utilizou-se o método de Dunn em seguida. Na região de molares direitos foi observada significância estatística (p=0,048) entre os grupos Controle e Prótese Parcial Fixa Sobre Implante. Quando a variável incisivos centrais foi examinada, verificou-se diferença estatística (p=0,036) entre o grupo Controle e o grupo Prótese Parcial Fixa Sobre Implante. Na área de incisivo lateral e canino a diferença estatisticamente significativa (p=0,003) foi averiguada apenas nas comparações envolvendo o grupo Controle, não sendo encontrada entre os grupos experimentais. Já nos molares esquerdos não foi observada diferença estatisticamente significativa entre os grupos (p=0,085). Concluiu-se que, apesar da força de mordida máxima mediana ter sido maior para o grupo prótese parcial fixa convencional, não é possível afirmar que a mesma apresenta função mastigatória superior à prótese parcial fixa sobre implante na região de incisivo lateral e canino em pacientes com fissura labiopalatina

The aim of this study was compare the maximal bite force among individuals without cleft lip and palate and with natural teeth, individuals with cleft lip and palate rehabilitated with implant-supported partial fixed prosthesis and individuals with cleft lip and palate rehabilitated with conventional partial fixed prosthesis, especially in the lateral incisor and canine region. For this, the subjects were divided in 2 groups: ImplantSupported Partial Fixed Prosthesis (n= 6) and Conventional Partial Fixed Prosthesis (n=10) and Control group (n=11). The bite force measurements were performed with a gnathodynamometer and statistically analyzed by Kruskal-Wallis test with a 0,05 significance level. When was verified statistical significance, the Dunn’s method was used. In the right molars region was observed statistical significance (p=0,048) between the groups Control and ImplantSupported Partial Fixed Prosthesis. When the central incisors variable was examined, there was a statistical difference (p=0,036) between Control group and Implant-Supported Partial Fixed Prosthesis group. In the lateral incisor and canine area the statistically significant difference (p=0,003) was ascertained only in comparisons involving the Control group, not being found between the experimental groups. Already in the left molars was not observed statistically significant difference between groups (p=0,085). It was concluded that, although the median maximal bite force has been greater for Conventional Partial Fixed Prosthesis group, it’s not possible affirm that it presents higher masticatory function than implant-supported partial fixed prosthesis in the lateral incisor and canine region in patients 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.

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.

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.

Conexão dente-implante: uma alternativa viável? Relato de Caso Clínico usando prótese parcial removível apoiada sobre dentes e implantes / Connection tooth-implant: a viable alternative?Case report using removable partial denture supported on teeth and implants

As fissuras labiopalatinas levam os profissionais a idealizarem próteses não convencionais na busca da solução das reabilitações por se tornarem, muitas vezes, bastante complexas. Próteses totalmente implanto-suportadas devem ser o tratamento de escolha, embora haja casos em que a união de dentes com implantes é inevitável. Há autores que defendem a união rígida, outros a não rígida e outros ainda que não recomendem a união dente-implante. Os riscos relacionados a esta união são resultado de diferenças biomecânicas entre as estruturas envolvidas, ligamento periodontal e osso, e da biomecânica dos dentes e implantes apoiados sobre as próteses. Objetivo: este trabalho relata um caso clínico de reabilitação oral com uma PPR sobre dentes unidos a implantes em uma paciente com fissura labiopalatina do Hospital de Reabilitação de Anomalias Craniofaciais de Bauru. Método: relato do caso. Resultados e Discussão: paciente de 47 anos, gênero feminino, portadora de fissura pós-forame incisivo incompleta, apresentava os dentes 13, 23 e 27, sendo este extraído por problemas periodontais, e 2 implantes instalados nas regiões dos dentes 16 e 26. O planejamento reabilitador protético foi a instalação de uma PPR com encaixe tipo barra-clip retida por 3 barras metálicas unindo os dentes aos implantes por meio de um sistema tubo parafuso. A união não-rígida demonstra maior distribuição das forças, embora possa causar a intrusão dentária. Já a união rígida, apresenta maior estresse e maior perda óssea na região dos implantes. Conclusão: o correto planejamento, embasado na biomecânica, assim como controles clínicos e rádio gráficos posteriores, são de suma importância para o sucesso do tratamento reabilitador protético...

Cleft lip and palate lead professionals to idealize unconventional prostheses to find the solution for the rehabilitation that becomes, oftentimes, complex. Totally implant-supported prostheses should be the treatment of choice, although there are cases in which the connection of teeth with implants is inevitable. Some authors advocate the rigid connection, others the non-rigid connection and still others do not recommend the implant-tooth connection. The risks related to this connection are the result of biomechanical differences between the structures involved, periodontal ligament and bone, and biomechanics of teeth and implants supported on the prostheses. Objective: this report presents a case of oral rehabilitation with a removable partial prosthesis on teeth connected to implants in a patient with cleft lip and palate in Hospital of Rehabilitation of Craniofacial Anomalies of Bauru. Method: case report. Results and Discussion: a 47 year old female patient, with incomplete post foramen cleft presenting the teeth 13, 23 and 27, which was extracted by periodontal problems, and two implants placed in regions of the teeth 16 and 26. The prosthetic rehabilitation treatment was the installation of a removable partial prosthesis with a bar-clip type of fit retained by 3 metal bars connecting teeth to implants through a tube screw system. The non-rigid connection demonstrates greater distribution of forces, although it can cause tooth intrusion...

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).

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.

Prótese parcial removível dento-implanto-suportada para paciente com fissura labiopalatal / Removable partial denture tooth and implant-supported at patient with cleft lip and palate

A prótese parcial removível (PPR) tem sido uma modalidade de tratamento fundamental para os pacientes fissurados parcialmente desdentados". Particularmente, os casos de extremidade livre apresentam grandes problemas>'. Na impossibilidade da reabilitação com próteses fixas sobre implantes, por razões biológicas ou financeiras, a associação de implantes com próteses parciais removíveis pode proporciona maior estabilidade, retenção, distribuição das forças oclusais, eficiência mastigatória, segurança e conforto para estes pacientes':". Este trabalho teve como objetivo apresentar um caso clínico de reabilitação com PPR dento-implanto-suportada, sendo assim, conclui-se que essa associação proporcionou melhor qualidade de vida ao paciente

The removable partial denture (RPD) have principal role in the treatment of patients with cleft partially edentulous, but the cases of distal extension show big problerns". In the impossi- bility of the rehabilitation with fixed prostheses on implants, for biological reasons or financial, the implants association with removable partial dentures proportionates bigger assurance and comfort at these patients':". This study had as aim present a clinical report of tooth-implant- supported RPD maxilla rehabilitation and, it may be concluded that: this conjuction proportio- nated better quality of life to this patient and that has studies necessity that value the effecti- veness of these type of treatment into a numeral greater than patients

Próteses provisórias implanto-suportadas / Implant-supported provisional prosthesis

Para uma adequada reabilitação oral protética, tanto nos dentes preparados como nos casos sobre implantes, existe a necessidade da confecção de próteses provisórias para restabelecer seus princípios funcionais, biológicos e mecânicos. Assim, o objetivo deste trabalho foi apresentar casos clínicos de próteses provisórias implanto-suportadas, suas versatilidades e importância para o sucesso do tratamento. Foram selecionados pacientes em tratamento odontológico no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC/USP), os quais receberam próteses unitárias, fixas e do tipo protocolo. Foi enfatizada a importância da prótese provisória no estabelecimento do perfil de emergência, sua utilização durante a moldagem de transferência dos implantes e, por final, uma prótese protocolo provisória feita com um reforço metálico, em vez de uma barra convencional. Considerando a importância da fase das próteses provisórias no tratamento reabilitador, o cirurgião-dentista deve explorar toda a possibilidade e versatilidade dessa fase para que o mínimo de dúvidas e adversidades ocorra na fase definitiva, proporcionando um prognóstico confiável.

A modified approach for vestibuloplasty in severely resorbed mandible using an implant-retained postoperative stent: a case report.

BACKGROUND: Severely resorbed mandibles often present a short band of keratinized tissue associated with a shallow vestibule. As a result, prominent muscle insertions are present, especially in the mental region of the mandible. This case report describes the deepening of the vestibular sulcus in an atrophic mandible by combining free gingival grafts harvested from the palate and a postoperative acrylic resin stent screwed on osseointegrated implants placed at the anterior region of the mandible. STUDY DESIGN: During the second-stage surgery, a split-thickness labial flap was reflected and apically sutured onto the periosteum. Two free gingival grafts were obtained and then sutured at this recipient site. A previously custom-made acrylic stent was then screwed onto the most distally positioned implants. To document the procedure's stability over time, a metal ball was placed in the most apical part of the vestibule and standardized cephalometric radiographs were taken before and 6 months after the procedure. Linear measurements of vestibular depths over the observation time were realized using specific software for radiographic analysis. RESULTS: The proposed technique augmented the band of attached masticatory mucosa, deepened the vestibule and prevented the muscle reinsertion. The difference between the 2 measurements of vestibular depths was 9.39 mm (initial 20.88 mm, final 11.49 mm) after a 6-month postoperative period. CONCLUSION: The technique, in combination with palatal mucosal graft and use of a postoperative stent, decreased the pull of mentalis muscle and provided a peri-implantally stable soft tissue around implants.

Técnica modificada de munhão personalizado: relato de caso clínico / Modified technique of personalized abutment: a case report

Os implantes ossoeintegrados vêm sendo muito utilizados no tratamento reabilitador de pacientes com fissura labiopalatina, já que anomalias dentais são as seqüelas mais comuns desta má-formação congênita. O presente artigo objetiva mostrar uma técnica modificada de munhão personalizado com aplicação de cerâmica diretamente no abutment, a fim de reabilitar o espaço do incisivo laterial o mais esteticamente possível.

Correction of a mucogingival defect using an implant-retained postoperative stent in a severely resorbed mandible: case report.

This case report describes a technique that uses a palatal mucosal graft and an acrylic resin postoperative stent in an attempt to increase the layer of keratinized tissue around osseointegrated implants in an atrophic mandible. During second-stage surgery, a split-thickness labial flap is reflected and apically repositioned by being sutured onto the periosteum and connective tissue. A palatal mucosal graft is then sutured onto the recipient site. The stent is worn for at least 4 weeks following surgery. This procedure helps to eliminate mobility of the mucosa in the area, deepen the vestibule, and prevent muscle reinsertion.

Shear bond strength fatigue limit of rest seats made with dental restoratives.

PURPOSE: This study compared the shear bond strength (SBS) to enamel of rest seats made with a glass-ionomer cement (Fuji IX GP Fast), a resin-modified glass-ionomer cement (Fuji II LC), and a composite resin (Z100 MP) under monotonic and cyclic loading. MATERIALS AND METHODS: Rest seats were built up onto the lingual surfaces of 80 intact human mandibular incisors. Specimens (n = 10) were stored in distilled water at 37 degrees C for 30 days and subjected to shear forces in a universal testing machine (0.5 mm/min) until fracture. The SBS values were calculated (MPa) using the bonding area (9.62 mm2) delimited by adhesive tags. A staircase approach was used to determine the SBS fatigue limit of each material. Specimens were submitted to either 10,000 cycles (5 Hz) or until specimen fracture. A minimum of 15 specimens was tested for each material. Scanning electron microscopy was used to examine the mode of failure. Data were statistically analyzed with one-way ANOVA and Tukey HSD tests (alpha = 0.05). RESULTS: Z100 MP yielded higher (p < 0.05) SBS (12.25 MPa) than Fuji IX GP Fast (7.21 MPa). No differences were found between Fuji II LC (10.29 MPa) and the other two materials (p > 0.05). Fuji II LC (6.54 MPa) and Z100 MP (6.26 MPa) had a similar SBS limit. Fuji IX GP Fast promoted the lowest (p < 0.05) SBS fatigue limit (2.33 MPa). All samples showed cohesive failure patterns. CONCLUSION: Fatigue testing can provide a better means of estimating the performance of rest seats made with dental restoratives.

Prótese imediata em implante unitário após enxerto ósseo em paciente fissurado: acompanhamento de um ano / Immediate prosthesis single implant after bone grafting in a patient with cleft lip and palate: one year follow-up

A reabilitação da região ântero-superior é uma das fases finais do tratamento das fissuras de lábio e palato, e os implantes têm-se tornado cada vez mais utilizados. Este trabalho apresenta um caso de instalação de implante com provisório imediato, após enxerto ósseo, em um paciente fissurado.

A importância da mucosa ceratinizada ao redor de implantes osseointegrados / The importance of the keratinized mucosa surrounding osseointegrated implants

A anatomia do tecido mole periimplantar é semelhante à do dente natural, uma vez que apresenta epitélio juncional e tecido conjuntivo. Entretanto, as fibras conjuntivas do dente (Sharpey) estão inseridas no osso e no cemento radicular, diferentemente das fibras que circundam o implante, pois essas apresentam uma disposição paralela em relação ao abutment (intermediário transmucoso). Portanto, o selamento periimplantar é estabelecido pela mucosa ceratinizada presente, por meio do tônus de suas fibras colágenas, proporcionando uma firme junção epitélio-implante. Assim, uma adequada faixa de mucosa ceratinizada é capaz de facilitar o controle de placa realizado pelo paciente; evita traumas no tecido mole (durante os procedimentos cirúrgicos e protéticos) e previne a migração apical da margem gengival, mantendo a homeostasia periimplantar e a estética. Enquanto não se tem um consenso na literatura sobre a quantidade adequada de zona de mucosa queratinizada em torno do implante, a presença desta mucosa parece trazer benefícios a prótese implantada.

The anatomy of soft tissue peri-implant is similar of the natural tooth in that there are connective-tissue attachment and juncional epithelial. However, the connective fibers of the tooth (Sharpey) are inserted in the bone and the cement of root, differently of the fibers that surround the implantation, therefore these present a parallel disposition in relation to abutment (intermediate transmucoso).Therefore, the sealing peri-implantar is established by the present keratinized mucosa by means of tonus of its collagens fibers, providing a firm junction epithelium-implant. Thus, one adjusted zone of keratinized mucosa is able to facilitate the plaque-control procedure, to prevent trauma in the soft tissue and to prevent the apical migration of the gingival edge, keeping the homeostasia periimplant and the aesthetic one. Until it isn’t consensus in literature about the quantity of adequate zone of keratinized mucosa around implants, the presence of this mucosa carries some benefits to implant prothesis.

Avaliação periodontal de dentes pilares em próteses parciais removíveis, não convencionais - de recobrimento - "overlay" / Periodontal evaluation of abutment teeth with partial removible protheses, non-conventional - overlay

Objetivos: Analisar o status periodontal dos dentes pilares e não pilares de indivíduos usuários de próteses "overlay" e correlacionar o tempo de instalação das próteses com as condições periodontais dos dentes remanescentes. Métodos: Foram avaliados 116 dentes de 16 indivíduos, de ambos os sexos, com idade entre 20 e 59 anos. Os parâmetros periodonatais avaliados foram: índice de placa, índice gengival, índice de Tarbet, profundidade de sondagem, quantidade de gengiva queratinizada e recessão gengival. Resultados: A média de profundidade de sondagem foi de 2,78 mm. Em 68% dos dentes não havia placa e 68,97% apresentaram saúde periodontal. Cerca de 93,97% dos dentes não apresentaram mobilidade, e em 85,35% havia presença de gengiva queratinizada maior ou igual a 2 mm. Não houve diferenças estatisticamente significantes entre dentes pilares e não pilares quanto ao índice de placa e índice gengival e foi significante quanto à profundidade de sondagem para P<0,05, apesar de proporcionalmente todos os índices terem sido maiores nos dentes pilares. Houve correlação positiva e significante entre índice de placa e de Tarbet (r=0.34, p=0.00). Conclusões: As próteses "overlay" devem ser indicadas para indivíduos com boa higiene oral ou para aqueles que se comprometam a realizar terapia de manutenção