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Inside Dentistry
May 2024
Volume 20, Issue 5
Peer-Reviewed

An Innovative Solution for Patients With Cleft Lip and Palate Defects

Rotational path removable partial dentures facilitate functional and esthetic anterior tooth replacement

Varisha Parikh, DMD

Patients with cleft lip and palate defects often face distinctive challenges when it comes to oral rehabilitation. The nature of the defect can result in significant discrepancies in tooth development and alignment, which can make it difficult for traditional orthodontic and surgical approaches to be successful. This case report illustrates the transformative impact that a rotational path removable partial denture can have for these patients.

The 32-year-old female patient in this case had been in active orthodontic treatment for more than 6 years. Although the patient's mandibular arch form had been idealized and her posterior occlusion had been established with 3 maxillary posterior teeth on either side, her impacted maxillary anterior teeth could not be moved, and scarring and a lack of bone resulting from her cleft lip and palate repair would prevent implant placement without extensive and unpredictable grafting surgeries. Therefore, a treatment plan involving a rotational path removable partial denture was developed and executed.

After all of the patient's orthodontic appliances were removed, and the impacted teeth (Nos. 5, 6, 11, and 12) were extracted, an interim partial denture was delivered to provide the patient with acceptable esthetics and to serve as a retainer for her remaining maxillary posterior teeth.

After an initial healing period, the case was remounted, and a diagnostic wax-up was completed for the remaining maxillary posterior teeth (Nos. 2, 3, 4, 13, 14, and 15). The diagnostic wax-up was used to determine the best possible occlusal relationship for the posterior teeth and also to determine the placement of the guide planes and undercuts necessary for the denture's framework design.

Next, the teeth were prepared for survey crowns, and impressions were acquired. After the correct vertical dimension was established and a wax rim was created for the laboratory and verified, a wax-up of the survey crowns was created and verified on a surveyor to confirm their design elements.

Once the survey crowns were placed, another impression was made to begin the design and fabrication of the framework for the rotational path removable partial denture. After the frame was fabricated, a try-in appointment was completed to verify its retention, support, and stability using acrylic denture teeth set in wax. The final rotational path removable partial denture included a heat-processed acrylic base with acrylic teeth.

Rotational path removable partial dentures have emerged as a beacon of hope for patients with cleft lip and palate defects. By combining innovative design with a patient-centric focus, these prostheses can enable patients to smile with confidence and lead fulfilling lives.

About the Author

Varisha Parikh, DMD
Private Practice
Los Angeles, California

(1.) Pretreatment retracted photograph showing the results of previous orthodontic treatment and impacted canines and first premolars in the premaxillary cleft area.

Figure 1

(2.) Right and left lateral retracted photographs showing the occlusal position between the maxillary second premolars, first molars, and second molars and the idealized mandibular arch.

Figure 2

(3.) Right and left lateral retracted photographs showing the occlusal position between the maxillary second premolars, first molars, and second molars and the idealized mandibular arch.

Figure 3

(4.) Pretreatment maxillary occlusal photograph showing the palatal expansion device that was utilized to expand the maxillary arch laterally to better match the mandibular arch.

Figure 4

(5.) Maxillary occlusal view following removal of the orthodontia as well as extraction of the impacted maxillary first premolars and canines.

Figure 5

(6.) Mandibular occlusal view demonstrating an idealized arch form. The only treatment completed on the mandibular arch was placement of a bonding splint for teeth Nos. 22 through 27 using a 35% phosphoric acid etchant (Ultra-Etch™, Ultradent), universal adhesive (3M™ Scotchbond™, 3M), and flowable composite (3M™ Filtek™ Supreme Flowable Restorative [A2], 3M).

Figure 6

(7.) Retracted view of the maxillary and mandibular occlusal relationship after removal of orthodontia and extraction of the impacted maxillary premolars and canines.

Figure 7

(8.) Occlusal view of the master cast demonstrating how the maxillary posterior teeth were prepared for survey crowns. The preparation design included minimal occlusal reduction given that the occlusal vertical dimension was increased and that the material of choice for the occlusal position was metal, with a metal lingual collar and a porcelain fused-to-metal design for the buccal contour.

Figure 8

(9.) Occlusal view of the master cast with a wax-up of the survey crowns designed for the rotational path removable partial denture. A splinted design was chosen for the survey crowns to help stabilize the posterior teeth and create proper rest seats, supports, and undercuts to retain the removable partial denture while maintaining adequate contours for hygiene.

Figure 9

(10.) Occlusal view of the fabricated survey crowns on the master cast.

Figure 10

(11.) Retracted view of the survey crowns after delivery. The occlusal position was corrected as much as possible utilizing the crown design for bilateral balance. Note the parallel guide planes on the anterior most teeth, which are crucial components of the rotational path system that help prevent the need for an anterior clasp assembly.

Figure 11

(12.) Occlusal view of the completed rotational path removable partial denture framework (Vitallium® Partial Denture System, Dentsply Sirona), which was fabricated using a wax and cast methodology, seated on the master cast.

Figure 12

(13.) Retracted occlusal view of the rotational path framework seated intraorally over the survey crowns. Note that there is no anterior clasp assembly and that there is a press-fit design between the support, stability, and retention components built into the survey crowns.

Figure 13

(14.) Smile photograph of the try-in of the removable partial denture with denture teeth (Portrait® IPN® Denture Teeth [A1], Dentsply Sirona) set in wax.

Figure 14

(15.) Smile photograph of the final removable partial denture seated intraorally on the survey crowns. The denture teeth were processed onto the framework using a high impact pink acrylic denture resin (Lucitone 199®, Dentsply Sirona) that was processed in a compression molding manner. Note how the lack of an anterior clasp assembly provides optimum esthetics.

Figure 15

Varisha Parikh, DMD

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