treatment of patients with cleft lip and palate calls for a complex multidisciplinary approach with long - term involvement . prosthodontists are integral members of this team because of the wide range of patient care services that they provide ( 1 ) . plastic surgeons , orthodontists , and prosthodontists are only part of the cleft palate team responsible for the medical care that , in many patients , starts shortly after birth and continues in various stages until maturity ( 2 ) . many patients with clefts that also affect the alveolar ridge present with either congenital absence of the permanent maxillary incisors , or with teeth that are in a rudimentary form , e.g. , peg - shaped or small crowns and short roots . this malpositioning , in addition to the tooth - lip relationship and the extent of hard and soft tissue deficiency , influences the esthetic appearance and phonetics ( 3 ) . thus , prosthodontists , when rehabilitating these patients , face the difficult decision of whether to use fixed or removable partial dentures ( fpds , rpds ) . in patients with severe deficiency , more extensive , advanced restorative care is required to resolve functional , esthetic , and phonetic problems . a combination of bone grafting and implant - supported fixed or removable prostheses is an invasive treatment approach . a conservative alternative treatment could be conventional fixed or removable prostheses for patients who refuse surgical intervention ( 4 ) . rpds are especially indicated in patients with tissue deficiency , several fistulae , soft palate dysfunction , or uncoordinated nasopharyngeal sphincter action , which can lead to hypernasal speech ( 3 ) . furthermore , it is suggested that a prosthesis may improve the psychological status of patients as well as their quality of life ( 5 ) . providing maxillofacial prosthetic treatment for patients with congenital and craniofacial defects should not only address physical and functional deficiencies but , ideally , should also consider the possible psychological effects of these deformities . unfortunately , only 20% of cleft palate teams worldwide perform psychological assessments of these patients ( 6 ) . this portion of the treatment evaluation is often overlooked or ignored and should be integrated into the overall treatment ( 7 ) . implant - supported fixed and removable prostheses , overdentures , and traditional fixed and removable prostheses can provide more normal facial contours , an improved smile line , improved arch relationships , and improved function in patients with facial defects . the authors have observed that patients with congenital craniofacial defects often feel more positive about themselves after prosthetic treatment . patients embarrassed by their teeth and facial appearance are frequently less motivated to maintain good oral hygiene or seek regular dental care , resulting in increased tooth loss and destruction of oral tissues ; this exacerbates an existing problem . early intervention can be extremely beneficial for the patient 's well - being ( 7 ) . prosthodontic care has a long and rich history in the care of patients with cleft lip and palate . with the increased knowledge of craniofacial growth and development and improved surgical and orthodontic treatment , today 's cleft patients receive better care and in less time ( 8) . the rpd could be a good alternative for some cleft patients in whom there are multiple missing teeth and an edentulous space that is too long to be spanned by a fixed restoration . this clinical report describes the rehabilitation of a cleft lip and palate patient using a rpd like an obturator . a 45-yr - old woman born with cleft lip and palate with congenitally absent bilateral maxillary incisors was referred to the department of prosthodontics in the school of dentistry , dicle university . clinical examination of the patient revealed poor oral hygiene and poorly fitting restorations ( fig . she presented with an inadequately repaired cleft lip and palate , and severe related psychosocial problems ( fig . the patient requested prostheses to into the left ureter for the purpose of palliation , the patient was submitted for atp - cra with an informed consent cial wellbeing . all teeth were extracted after periodontal treatment except the mandibular right first premolar , maxillary right canine , first premolar , second molar and maxillary left second molar . following a dental prophylaxis and oral hygiene instructions , the patient was placed on a 0.12% chlorhexidine gluconate oral rinse ( periogard oral rinse ; colgate oral pharmaceuticals , canton , ma , u.s.a . ) with twice daily recommended use . to satisfy the patient 's primary concerns , a treatment plan was developed that included placement of metal - ceramic crowns of mandibular right first premolar , maxillary right canine and first premolar . considering the clinical situation , maxillary and mandibular rpds were determined to be the treatment of choice . although a plan of implant treatment was presented to the patient as part of the primary treatment option , the patient declined these treatment modalities due to the financial burden . maxillary and mandibular complete - arch impressions were made using irreversible hydrocolloid impression material ( jeltrate , alginate , fast set ; dentsply intl , york , pa , u.s.a . ) . diagnostic casts were fabricated from type iv dental stone ( silky- rock ; whip mix corp , louisville , ky , u.s.a . ) and mounted on a semi - adjustable articulator ( articulator # 3140 ; whip mix corp ) using a face - bow transfer ( # 8645 quick mount face - bow ; whip mix corp ) and a centric relation record ( take 1 bite ; kerr corp , orange , ca , u.s.a . ) . the articulator was programmed using protrusive and lateral records ( coprwax bite wafers ; heraeus kulzer , south bend , in , u.s.a . ) . mandibular right first premolar , maxillary right canine and first premolar teeth were prepared for metal - ceramic restorations . laboratory - processed provisional restorations ( temdent , weil - dental , rosbach , germany ) were fabricated and cemented with zinc - oxide eugenol ( tempbond ; kerr corp ) . irreversible hydrocolloid impressions ( jeltrate , alginate , fast set ; dentsply intl ) of the provisional restorations were obtained and poured in type iv dental stone ( silky - rock ; whip mix corp ) . a custom incisal guide table was fabricated from acrylic resin ( pattern resin ls ; gc america ) . definitive impressions of the prepared teeth were obtained using hydrophilic addition silicone impression material ( elite hd+ , zhermack , rovigo , italy ) . working casts were generated from type iv die stone ( jade stone ; whip mix corp ) and mounted onto the articulator using interocclusal records ( take 1 bite ; kerr corp ) . following the normal clinical sequence , the marginal fitting and esthetic appearance of veneers were verified . a trial evaluation of the metal substructure , prior to glazing of the ceramic material , enabled final occlusal refinement . the crowns were cemented with zinc polycarboxylate cement ( poly f plus ; dentsply detrey gmbh , konstanz , germany ) using the manufacturer 's recommended powder / liquid ratio . after crown cementation , preliminary impressions were made with irreversible hydrocolloid ( kromopan ; lascod spa , florence , italy ) for rpds . custom trays were fabricated with autopolymerized acrylic resin ( duracryl ; spofa dental , prague , czech republic ) , and definitive impressions ( zetaplus , thixoflex ; zhermack , rovigo , italy ) were made . the occlusion and position of the prosthetic teeth were evaluated intraorally , and the necessary corrections were made before processing the dentures . instructions were given to the patient and she maintained a soft diet for the first few days to facilitate accommodation ; the necessity of regular cleaning and maintenance was also explained . the patient was instructed to remove the dentures at night and to present the following day and once a week for a period of two months for inspection and possible corrections and adjustment ( fig . in addition to oral hygiene instructions , the patient was prescribed a topical 1.1% neutral sodium fluoride ( prevident ; colgate oral pharmaceuticals ) with recommended daily use . recall evaluations at four - month intervals occurred for a period of one year , and the patient did not experience any complication associated with the oral rehabilitation . sessions after completion of treatment , the patient reported her great satisfaction with the outcome , and her family described her resultant more extroverted character ( fig . the rpd treatment selected , albeit invasive , is more conservative than the considered alternatives . other treatment methods involving implant - supported fixed dentures are considerably more radical and have greater incidence of clinical complications than conventional removable prosthodontics ( 9 , 10 ) . furthermore , this patient 's limited financial resources precluded the selection of a costly treatment . therefore , rpds were used , the patient 's oral hygiene was maintained to an acceptable level , and both the esthetic and functional results of the restorations were satisfactory . when evaluating a patient with congenital abnormalities , the initial steps involve inspection of appropriate occlusal vertical dimension ( ovd ) . insufficient ovd may be secondary to lack of teeth , abraded and worn teeth , altered anatomy intraorally and extraorally , or inadequate arch development . many variables determine the appropriate ovd to restore functional occlusion and facial support in each patient . these processes include an evaluation of speaking space , interocclusal distance , facial contours , lip contours , speech , condition of remaining teeth , and occlusion . a thorough assessment evaluates the need for periodontal care , endodontic treatment , orthodontic treatment , oral and maxillofacial surgery , or plastic surgery either prior to or during the maxillofacial prosthetic treatment . other factors , such as work and/or family commitment , may contribute to the course of the prosthetic and other treatments selected . treatment such as orthognathic surgery , bone grafts , and orthodontics , which would require more treatment time , may not be possible options ( 7 ) . to illustrate , this 45-yr - old woman presented with an inadequately repaired cleft lip and palate . the patient desired only prostheses to improve her situation to the extent possible , and maxillary and mandibular rpds were fabricated .   for some patients , it may be better to consider a more expedient treatment that obtains a high degree of success versus a long - term complicated treatment involving multiple procedures and increased expense during the critical development phase of adolescence or young adulthood . the more expedient treatment can give an individual more immediate esthetic , functional , and psychological support . the treatment of patients with congenital craniofacial defects presents psychosocial as well as technical challenges . in the general population , physical attractiveness contributes to a positive self - concept and social wellbeing ( 11 ) . the research of social psychologists describes the self - fulfilling nature of social stereotypes : appearance forms the basis for responses and impressions by others , which then influence individual behavior ( 12 ) . research has shown that global self - esteem is highly determined by assessment of one 's own physical presentation , as well as by comparisons with the attractiveness , ability , intellectual skills , and social acceptance of other people ( 13 ) . unusual facial features exacerbate the social challenges of meeting new people and getting along with others ( 14 ) . lowered self - esteem , speech defects , decreased academic performance , and social isolation these factors can contribute to inappropriate acting out and impaired social interactions ( 15 ) . a combination of fixed , implant - supported and removable prostheses in conjunction with other dental and medical treatment is often necessary to obtain the maximum and ideal outcome for the patient . maxillofacial prosthetic treatment allows these patients to feel more normal , and to have better selfesteem , greater opportunity to fulfill their potential socially , and improved employment possibilities ( 16 ) .
this clinical report described the oral rehabilitation of a cleft lip and palate patient with removable partial denture . 
 although implant - supported fixed treatment was presented as part of the optimum treatment plan to achieve the best result , the patient declined this option due to the significant financial burden . 
 persons with a congenital or craniofacial defect are unique , and oral problems must be evaluated individually to the most ideal treatment . 
 the changes in appearance , function , and psychological wellbeing have an enormous impact on patients ' personal lives and are rewarding for the maxillofacial prosthodontist providing this care .