DENTAL TECHNIQUE
Fabrication of lithium silicate ceramic veneers with a CAD/CAM approach: A clinical report of cleidocranial dysplasia Leonardo Fernandes da Cunha, DDS, MSc, PhD,a Eduardo Mukai, DDS,b Raphael Meneghetti Hamerschmitt, DDS, MSc, PhD,c and Gisele Maria Correr, DDS, MSc, PhDd
After the improvement of ABSTRACT dental computer-aided design/ The fabrication of minimally invasive ceramic veneers remains a challenge for dental restorations computer-aided manufacinvolving computer-aided design and computer-aided manufacturing (CAD/CAM). The application turing (CAD/CAM) systems of an appropriate CAD/CAM protocol and correlation mode not only simplifies the fabrication of and ceramic materials, CAD/ ceramic veneers but also improves the resulting esthetics. Ceramic veneers can restore tooth abCAM veneer restoration has normalities caused by disorders such as cleidocranial dysplasia, enamel hypoplasia, or supernumerary teeth. This report illustrates the fabrication of dental veneers with a new lithium silicate become a routine procedure in ceramic and the CAD/CAM technique in a patient with cleidocranial dysplasia. (J Prosthet Dent many dental practices. CAD/ 2015;113:355-359) CAM restorations reestablish function and improve esthetics for preserving enamel, especially in the marginal area.4 and may be performed in the dental office, saving the Additionally, after milling and before the cementation patient and clinician time by reducing the need for process, the application of an adequate porcelain veneer multiple appointments.1 However, the optimal protocol finishing procedure is essential to ensure good esthetics for ensuring clinical success with laminate veneers with CAD/CAM systems is unclear.1-3 and to guarantee an appropriate emergence profile and margins.3 The use of CAD/CAM systems for rehabilitation Glass ceramics are indicated for esthetic veneer reswith veneers includes restorative planning. Before the torations because of their optical properties and acidfabrication of the dental restorations, the form and size sensitivity.5 Recently, a zirconia-reinforced, higher of the teeth are designed from a diagnostic cast, and a strength lithium silicate-reinforced ceramic that features virtual model is created from evaluative intraoral a fine-grained and homogenous microstructure and that restoration scans. The correlation mode, which offers supports a wide range of applications, including anterior the option to cut and paste a scanned restoration, is recommended for veneers because the personalized and posterior crowns and laminate veneers, has become planning improves the definitive functional parameters available for CAD/CAM systems. Cleidocranial dysplasia (CCD) is an autosomaland esthetics.2,3 dominant disorder that affects one in 1 000 000 inWhen proposing the use of CAD/CAM systems for dividuals. CCD is characterized by orofacial defects, the restoration of porcelain veneers, the thickness and including enamel hypoplasia and impacted permanent marginal area of the teeth must be considered. The and supernumerary teeth.6 A restorative approach selection of a minimally invasive preparation is essential
a
Professor, Graduate Program of Dentistry, Positivo University, Curitiba, Brazil. Graduate student, Master Program, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil. c Graduate student, Graduate Program of Dentistry, Positivo University, Curitiba, Brazil. d Professor, Graduate Program of Dentistry, Positivo University, Curitiba, Brazil. b
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Figure 1. Preoperative view of 29-year-old woman with cleidocranial dysplasia with compromised esthetics due to anatomic discrepancies in form, shape, and color of composite resin restorations. Gingival contouring was not harmonious with existing architecture.
such as indirect veneers can be used to improve esthetics in patients with orofacial disorders. This article describes a clinical protocol for the chairside CAD/CAM fabrication of glass ceramic laminate veneers for esthetic improvements in an individual with CCD. TECHNIQUE 1. Discuss treatment options with the patient. Evaluate the tooth size, form, color, and gingival contour; assess the presence of previous restorations, and occlusal guidance (anterior and lateral); and select the desired color of the teeth before drying (Fig. 1). 2. Make a complete-arch impression and fabricate a diagnostic cast. Wax the desired restoration
Volume 113 Issue 5
contours to define the shape and form. In a subsequent appointment, create an impression of the diagnostic waxing with polyvinyl siloxane (Express XT; 3M ESPE). Fill the cast with bis-acryl resin (ProTemp 4; 3M ESPE) and place intraorally to evaluate the restorations (Fig. 2). Press occlusal surfaces of the matrix to ensure accurate seating and allow the bis-acryl resin to polymerize according to the manufacturer’s instructions. 3. After polymerization of the bis-acryl resin, visually verify the size, form, and incisal angles of the evaluative restorations, cut back the gingival excess with a surgical blade, and evaluate the occlusal contacts. Observe the upper lip and incisal contour, and study functional movements of the patient. Allow the patient to evaluate the esthetics. Fabricate an intraoral digital impression with an intraoral handheld scanner (Sirona Cerec; Sirona Dental Systems) and obtain a complete-arch dental scan with the evaluative restorations in position. Scan the antagonist arch and the occlusal record to design the anatomy of incisal and occlusal teeth to optimize occlusion (Fig. 3). 4. Remove the evaluative restorations and existing composite resin and perform a minimal tooth preparation with diamond rotary instruments with a chamfer at the cervical area (Fig. 4). Refine the prepared teeth with fine-grit diamond rotary instruments and aluminum oxide-coated disks (Soflex; 3M ESPE) at a low speed without water spray. Make a digital impression with a displacement cord (Pro Retract; FGM Ind) in position. Afterward, make conventional impressions with polyvinyl siloxane. 5. Use the design tool to follow and track the preparation margins. Select the desired block (Vita Suprinity 1M1HT block; Vita Zahnfabrik) and place in the milling machine. During the milling procedure, prepare the dental cast from the
Figure 2. A, Diagnostic waxing used for analysis. B, Evaluative restorations used to capture specific line angles, facial anatomy, and contour before tooth preparation.
THE JOURNAL OF PROSTHETIC DENTISTRY
da Cunha et al
May 2015
Figure 3. Intraoral camera scanner was used to capture contour details of evaluative restorations and adjacent teeth. Antagonist images and interocclusal registration were also captured.
357
Figure 4. Teeth prepared for veneers after removal of composite resin restorations. Note enamel hypoplasia and dental size and shape anomalies present in all maxillary teeth. Preparation of left central incisor with cervical enamel preserved.
Figure 5. A, Lithium silicate ceramic veneer after milling procedure. B, Anterior teeth after placing correct size veneers in initial crystallization stage. C, Emergence profile, marginal area, and shape of veneers optimized by hand on dental cast from conventional impression.
conventional impression. After completing the veneer milling process, place the veneers on the prepared teeth to confirm adaptation, size, and form. Manually optimize the marginal areas of the veneers over the dental cast during the first da Cunha et al
crystallization stage. Perform additional refining to obtain the proper shape and contour for light reflection and the emergence profile. 6. Repeat the confirmation of the adaptation of the veneers and allow the patient to evaluate the
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Figure 6. A, Evaluation of definitive shape; B, Glass ceramic characterized with veneering ceramic.
porcelain polishing wheels (Rotatory Polishing Silicone; Jota AG) (Fig. 7). DISCUSSION
Figure 7. Anterior teeth restored with minimally invasive laminate veneers fabricated with CAD/CAM system.
definitive shape and size (Fig. 5). Perform the crystallization, and apply additional layering ceramic (VM11; Vita Zahnfabrik) to characterize the incisal edge (Fig. 6). 7. Acid-etch the internal surfaces of the veneers (Porcelain Etchant; FGM Dental Products) for 20 seconds. Wash and dry the veneers, apply 1 coat of adhesive (Single Bond Universal; 3M ESPE), and allow the adhesive to polymerize. Isolate the area and apply the adhesive system on the tooth surface (etch with phosphoric acid gel, rinse with water and dry, follow with application of the lightpolymerizing adhesive resin, and spread into a thin layer with a gentle air). Apply a light polymerizing cement (Nexus 3; Kerr Corp) to the veneers, remove any excess cement, and light polymerize with an LED device (Radii-cal; SDI Ltd) for 120 seconds for each tooth. 8. Remove gingival excess with a surgical blade. Evaluate for occlusal interferences and make any necessary adjustments. Polish the areas with
THE JOURNAL OF PROSTHETIC DENTISTRY
The application of CAD/CAM technology in dentistry allows for the provision of state-of-the-art dental services and time-saving advantages with a reduction in the need for multiple patient appointments.7 Furthermore, the accompanying software allows for ease of system handling and the application of new materials.3,8 The chief disadvantage is the cost of the system. The blocks used when fabricating ceramic veneers can be milled in a precrystallization phase when the shape and form can be optimized manually.5,9 The translucency of the material allows for the evaluation of the ceramic thickness over the tooth preparation. As demonstrated, lithium silicate ceramic veneer can be used as the core material, and subsequent coats of ceramic can be added to improve the appearance of the veneers. Restorative approaches to CCD remain a challenge in dentistry.6 Gingival therapy was considered an acceptable and conservative alternative for the current CCD patient, but the patient declined the suggested treatment. Thus, glass ceramic laminate veneers were fabricated with the CAD/CAM approach. To allow for future changes to the restoration and to improve the longevity of the adhesion, the dental preparation was restricted to the enamel, especially at the left central incisor, for a more conservative approach.4,10 In addition, the cervical area of the left central incisor was restored with pink composite resin. SUMMARY A technique for the fabrication of minimally invasive lithium silicate ceramic veneers for patients with CCD with the CAD/CAM system is described. With this technique, the waxing cast and evaluative restorations were combined, which allowed the use of the CAD/CAM correlation mode. da Cunha et al
May 2015
359
Consequently, the technique enabled the fabrication of esthetically successful veneer restorations. REFERENCES 1. Fasbinder DJ. Computerized technology for restorative dentistry. Am J Dent 2013;26:115-20. 2. Vafiadis D, Goldstein G. Single visit fabrication of a porcelain laminate veneer with CAD/CAM technology: a clinical report. J Prosthet Dent 2011;106:71-3. 3. Schmitter M, Seydler BB. Minimally invasive lithium disilicate ceramic veneers fabricated using chairside CAD/CAM: a clinical report. J Prosthet Dent 2012;107:71-4. 4. Cunha LF, Pedroche LO, Gonzaga CC, Furuse AY. Esthetic, occlusal and periodontal rehabilitation of anterior teeth with minimum thickness porcelain laminate veneers. J Prosthet Dent 2014;112:1315-8. 5. Ozcan M, Allahbeickaraghi A, Dündar M. Possible hazardous effects of hydrofluoric acid and recommendations for treatment approach: a review. Clin Oral Investig 2012;16:15-23. 6. da Cunha LF, Caetano IM, Dalitz F, Gonzaga CC, Mondelli J. Cleidocranial dysplasia case report: remodeling of teeth as aesthetic restorative treatment. Case Rep Dent 2014:901071.
7. Otto T, Schneider D. Long-term clinical results of chairside Cerec CAD/CAM inlays and onlays: a case series. Int J Prosthodont 2008;21:53-9. 8. Santos GC Jr, Santos MJ Jr, Rizkalla AS, Madani DA, El-Mowafy O. Overview of Cerec CAD/CAM chairside system. Gen Dent 2013;61:36-40. 9. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prosthodont 2012;25: 79-85. 10. da Cunha LF, Reis R, Santana L, Romanini JC, Carvalho RM, Furuse AY. Ceramic veneers with minimum preparation. Eur J Dent 2013;7:492-6. Corresponding author: Dr Leonardo Fernandes da Cunha Positivo University Rua Professor Pedro Viriato Parigot de Souza, 5300 Curitiba-PR, 81280-330 BRAZIL Email: [email protected] Acknowledgment The authors thank Elísio Ribeiro, who performed the waxing, design, and veneer characterization. Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Decision making for residual palatoalveolar cleft defects: A new classification Destruhaut F, Pomar P, Esclassan R, Rignon-Bret C Int J Prosthodont 2015;28:167-8 Oral rehabilitation of adult patients with cleft lip and palate is related to the severity of the anatomical and functional alterations that hamper the proper closure of the nasopharynx. The ideal treatment is closure by bone graft and orthodontics. However, when surgery is not possible or when the patient does not wish to undergo surgery, a palatal prosthesis may offer the best solution in most clinical situations. The authors of this article propose a new classification to help the practitioner with decision making and prosthetic treatment planning for residual palatoalveolar cleft defects.
da Cunha et al
THE JOURNAL OF PROSTHETIC DENTISTRY
Fabrication of lithium silicate ceramic veneers with a CAD/CAM approach: A clinical report of cleidocranial dysplasia Leonardo Fernandes da Cunha, DDS, MSc, PhD,a Eduardo Mukai, DDS,b Raphael Meneghetti Hamerschmitt, DDS, MSc, PhD,c and Gisele Maria Correr, DDS, MSc, PhDd
After the improvement of ABSTRACT dental computer-aided design/ The fabrication of minimally invasive ceramic veneers remains a challenge for dental restorations computer-aided manufacinvolving computer-aided design and computer-aided manufacturing (CAD/CAM). The application turing (CAD/CAM) systems of an appropriate CAD/CAM protocol and correlation mode not only simplifies the fabrication of and ceramic materials, CAD/ ceramic veneers but also improves the resulting esthetics. Ceramic veneers can restore tooth abCAM veneer restoration has normalities caused by disorders such as cleidocranial dysplasia, enamel hypoplasia, or supernumerary teeth. This report illustrates the fabrication of dental veneers with a new lithium silicate become a routine procedure in ceramic and the CAD/CAM technique in a patient with cleidocranial dysplasia. (J Prosthet Dent many dental practices. CAD/ 2015;113:355-359) CAM restorations reestablish function and improve esthetics for preserving enamel, especially in the marginal area.4 and may be performed in the dental office, saving the Additionally, after milling and before the cementation patient and clinician time by reducing the need for process, the application of an adequate porcelain veneer multiple appointments.1 However, the optimal protocol finishing procedure is essential to ensure good esthetics for ensuring clinical success with laminate veneers with CAD/CAM systems is unclear.1-3 and to guarantee an appropriate emergence profile and margins.3 The use of CAD/CAM systems for rehabilitation Glass ceramics are indicated for esthetic veneer reswith veneers includes restorative planning. Before the torations because of their optical properties and acidfabrication of the dental restorations, the form and size sensitivity.5 Recently, a zirconia-reinforced, higher of the teeth are designed from a diagnostic cast, and a strength lithium silicate-reinforced ceramic that features virtual model is created from evaluative intraoral a fine-grained and homogenous microstructure and that restoration scans. The correlation mode, which offers supports a wide range of applications, including anterior the option to cut and paste a scanned restoration, is recommended for veneers because the personalized and posterior crowns and laminate veneers, has become planning improves the definitive functional parameters available for CAD/CAM systems. Cleidocranial dysplasia (CCD) is an autosomaland esthetics.2,3 dominant disorder that affects one in 1 000 000 inWhen proposing the use of CAD/CAM systems for dividuals. CCD is characterized by orofacial defects, the restoration of porcelain veneers, the thickness and including enamel hypoplasia and impacted permanent marginal area of the teeth must be considered. The and supernumerary teeth.6 A restorative approach selection of a minimally invasive preparation is essential
a
Professor, Graduate Program of Dentistry, Positivo University, Curitiba, Brazil. Graduate student, Master Program, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil. c Graduate student, Graduate Program of Dentistry, Positivo University, Curitiba, Brazil. d Professor, Graduate Program of Dentistry, Positivo University, Curitiba, Brazil. b
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Figure 1. Preoperative view of 29-year-old woman with cleidocranial dysplasia with compromised esthetics due to anatomic discrepancies in form, shape, and color of composite resin restorations. Gingival contouring was not harmonious with existing architecture.
such as indirect veneers can be used to improve esthetics in patients with orofacial disorders. This article describes a clinical protocol for the chairside CAD/CAM fabrication of glass ceramic laminate veneers for esthetic improvements in an individual with CCD. TECHNIQUE 1. Discuss treatment options with the patient. Evaluate the tooth size, form, color, and gingival contour; assess the presence of previous restorations, and occlusal guidance (anterior and lateral); and select the desired color of the teeth before drying (Fig. 1). 2. Make a complete-arch impression and fabricate a diagnostic cast. Wax the desired restoration
Volume 113 Issue 5
contours to define the shape and form. In a subsequent appointment, create an impression of the diagnostic waxing with polyvinyl siloxane (Express XT; 3M ESPE). Fill the cast with bis-acryl resin (ProTemp 4; 3M ESPE) and place intraorally to evaluate the restorations (Fig. 2). Press occlusal surfaces of the matrix to ensure accurate seating and allow the bis-acryl resin to polymerize according to the manufacturer’s instructions. 3. After polymerization of the bis-acryl resin, visually verify the size, form, and incisal angles of the evaluative restorations, cut back the gingival excess with a surgical blade, and evaluate the occlusal contacts. Observe the upper lip and incisal contour, and study functional movements of the patient. Allow the patient to evaluate the esthetics. Fabricate an intraoral digital impression with an intraoral handheld scanner (Sirona Cerec; Sirona Dental Systems) and obtain a complete-arch dental scan with the evaluative restorations in position. Scan the antagonist arch and the occlusal record to design the anatomy of incisal and occlusal teeth to optimize occlusion (Fig. 3). 4. Remove the evaluative restorations and existing composite resin and perform a minimal tooth preparation with diamond rotary instruments with a chamfer at the cervical area (Fig. 4). Refine the prepared teeth with fine-grit diamond rotary instruments and aluminum oxide-coated disks (Soflex; 3M ESPE) at a low speed without water spray. Make a digital impression with a displacement cord (Pro Retract; FGM Ind) in position. Afterward, make conventional impressions with polyvinyl siloxane. 5. Use the design tool to follow and track the preparation margins. Select the desired block (Vita Suprinity 1M1HT block; Vita Zahnfabrik) and place in the milling machine. During the milling procedure, prepare the dental cast from the
Figure 2. A, Diagnostic waxing used for analysis. B, Evaluative restorations used to capture specific line angles, facial anatomy, and contour before tooth preparation.
THE JOURNAL OF PROSTHETIC DENTISTRY
da Cunha et al
May 2015
Figure 3. Intraoral camera scanner was used to capture contour details of evaluative restorations and adjacent teeth. Antagonist images and interocclusal registration were also captured.
357
Figure 4. Teeth prepared for veneers after removal of composite resin restorations. Note enamel hypoplasia and dental size and shape anomalies present in all maxillary teeth. Preparation of left central incisor with cervical enamel preserved.
Figure 5. A, Lithium silicate ceramic veneer after milling procedure. B, Anterior teeth after placing correct size veneers in initial crystallization stage. C, Emergence profile, marginal area, and shape of veneers optimized by hand on dental cast from conventional impression.
conventional impression. After completing the veneer milling process, place the veneers on the prepared teeth to confirm adaptation, size, and form. Manually optimize the marginal areas of the veneers over the dental cast during the first da Cunha et al
crystallization stage. Perform additional refining to obtain the proper shape and contour for light reflection and the emergence profile. 6. Repeat the confirmation of the adaptation of the veneers and allow the patient to evaluate the
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Volume 113 Issue 5
Figure 6. A, Evaluation of definitive shape; B, Glass ceramic characterized with veneering ceramic.
porcelain polishing wheels (Rotatory Polishing Silicone; Jota AG) (Fig. 7). DISCUSSION
Figure 7. Anterior teeth restored with minimally invasive laminate veneers fabricated with CAD/CAM system.
definitive shape and size (Fig. 5). Perform the crystallization, and apply additional layering ceramic (VM11; Vita Zahnfabrik) to characterize the incisal edge (Fig. 6). 7. Acid-etch the internal surfaces of the veneers (Porcelain Etchant; FGM Dental Products) for 20 seconds. Wash and dry the veneers, apply 1 coat of adhesive (Single Bond Universal; 3M ESPE), and allow the adhesive to polymerize. Isolate the area and apply the adhesive system on the tooth surface (etch with phosphoric acid gel, rinse with water and dry, follow with application of the lightpolymerizing adhesive resin, and spread into a thin layer with a gentle air). Apply a light polymerizing cement (Nexus 3; Kerr Corp) to the veneers, remove any excess cement, and light polymerize with an LED device (Radii-cal; SDI Ltd) for 120 seconds for each tooth. 8. Remove gingival excess with a surgical blade. Evaluate for occlusal interferences and make any necessary adjustments. Polish the areas with
THE JOURNAL OF PROSTHETIC DENTISTRY
The application of CAD/CAM technology in dentistry allows for the provision of state-of-the-art dental services and time-saving advantages with a reduction in the need for multiple patient appointments.7 Furthermore, the accompanying software allows for ease of system handling and the application of new materials.3,8 The chief disadvantage is the cost of the system. The blocks used when fabricating ceramic veneers can be milled in a precrystallization phase when the shape and form can be optimized manually.5,9 The translucency of the material allows for the evaluation of the ceramic thickness over the tooth preparation. As demonstrated, lithium silicate ceramic veneer can be used as the core material, and subsequent coats of ceramic can be added to improve the appearance of the veneers. Restorative approaches to CCD remain a challenge in dentistry.6 Gingival therapy was considered an acceptable and conservative alternative for the current CCD patient, but the patient declined the suggested treatment. Thus, glass ceramic laminate veneers were fabricated with the CAD/CAM approach. To allow for future changes to the restoration and to improve the longevity of the adhesion, the dental preparation was restricted to the enamel, especially at the left central incisor, for a more conservative approach.4,10 In addition, the cervical area of the left central incisor was restored with pink composite resin. SUMMARY A technique for the fabrication of minimally invasive lithium silicate ceramic veneers for patients with CCD with the CAD/CAM system is described. With this technique, the waxing cast and evaluative restorations were combined, which allowed the use of the CAD/CAM correlation mode. da Cunha et al
May 2015
359
Consequently, the technique enabled the fabrication of esthetically successful veneer restorations. REFERENCES 1. Fasbinder DJ. Computerized technology for restorative dentistry. Am J Dent 2013;26:115-20. 2. Vafiadis D, Goldstein G. Single visit fabrication of a porcelain laminate veneer with CAD/CAM technology: a clinical report. J Prosthet Dent 2011;106:71-3. 3. Schmitter M, Seydler BB. Minimally invasive lithium disilicate ceramic veneers fabricated using chairside CAD/CAM: a clinical report. J Prosthet Dent 2012;107:71-4. 4. Cunha LF, Pedroche LO, Gonzaga CC, Furuse AY. Esthetic, occlusal and periodontal rehabilitation of anterior teeth with minimum thickness porcelain laminate veneers. J Prosthet Dent 2014;112:1315-8. 5. Ozcan M, Allahbeickaraghi A, Dündar M. Possible hazardous effects of hydrofluoric acid and recommendations for treatment approach: a review. Clin Oral Investig 2012;16:15-23. 6. da Cunha LF, Caetano IM, Dalitz F, Gonzaga CC, Mondelli J. Cleidocranial dysplasia case report: remodeling of teeth as aesthetic restorative treatment. Case Rep Dent 2014:901071.
7. Otto T, Schneider D. Long-term clinical results of chairside Cerec CAD/CAM inlays and onlays: a case series. Int J Prosthodont 2008;21:53-9. 8. Santos GC Jr, Santos MJ Jr, Rizkalla AS, Madani DA, El-Mowafy O. Overview of Cerec CAD/CAM chairside system. Gen Dent 2013;61:36-40. 9. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prosthodont 2012;25: 79-85. 10. da Cunha LF, Reis R, Santana L, Romanini JC, Carvalho RM, Furuse AY. Ceramic veneers with minimum preparation. Eur J Dent 2013;7:492-6. Corresponding author: Dr Leonardo Fernandes da Cunha Positivo University Rua Professor Pedro Viriato Parigot de Souza, 5300 Curitiba-PR, 81280-330 BRAZIL Email: [email protected] Acknowledgment The authors thank Elísio Ribeiro, who performed the waxing, design, and veneer characterization. Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Decision making for residual palatoalveolar cleft defects: A new classification Destruhaut F, Pomar P, Esclassan R, Rignon-Bret C Int J Prosthodont 2015;28:167-8 Oral rehabilitation of adult patients with cleft lip and palate is related to the severity of the anatomical and functional alterations that hamper the proper closure of the nasopharynx. The ideal treatment is closure by bone graft and orthodontics. However, when surgery is not possible or when the patient does not wish to undergo surgery, a palatal prosthesis may offer the best solution in most clinical situations. The authors of this article propose a new classification to help the practitioner with decision making and prosthetic treatment planning for residual palatoalveolar cleft defects.
da Cunha et al
THE JOURNAL OF PROSTHETIC DENTISTRY
