Maxillofacial Prosthetics

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2013

DR RITESH SHIWAKOTI

History

Artificial facial parts found on Egyptian

mummies long time ago.

Ancient Chinese known to have made facial

restorations.

1953 -- American Academy of Maxillofacial

Prosthetics founded.

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Overview

Maxillofacial prosthetics is a branch

of prosthodontics in dentistry.

Main aim is to restore the function

and esthetics of an individual.

Its also approve a psychological

state of a patient after a trauma or

surgery.

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Maxillofacial Prosthetics

The art and science of anatomic,

functional, or cosmetic reconstruction by

means of nonliving substitutes of those

regions in the maxilla, mandible, and

face that are missing or defective

because of surgical intervention, trauma,

pathology, or developmental or

congenital malformations.

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Type of M.F.P

Intra-Oral

Extra-Oral

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Indications of MFP

After surgical intervention.

After trauma.

Congenital defects.

Acquired defects.

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Prosthetic vs. Surgical Rehabilitation

Individualized decision between

patient and doctor.

Removable prosthesis allows for

cancer surveillance.

Destruction amount.

Malignancy recurrence.

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Intraoral vs. Extraoral

Intraoral -- mostly functional

Mandible

Maxilla

Extraoral -- cosmetic

Ear

Nose

Orbit

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Management of patient for MFP.

Personal history of a patient should be obtained.

Dental and medical history also should be

obtained.

Intra and external examination of a patient by a

maxillofacial surgeon and prosthodontics should

be done.

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Management of patient for MFP.

Patients risk assessment should be

done.

A surgeon should consulate with a

dentist about a surgery so that there

should be a team work.

All surgical alterations should be

demonstrated for a dentist on a cast

and obturator should be made for a

day of a surgery.

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Psychosocial Issues 11

Dental Impression

Surgeon has

marked

resection for

prosthodonti

c planning.

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Post surgical management.

After a surgery and even before it’s a team work for a

rehabilitation of a patient that includes:

1. Maxillofacial surgeon.

2. Prosthodontics.

3. Orthodontist.

4. Phycastrist

5. Speech rehabilitation specialist.

6. Oncologist.

7. Plastic surgeon specialist

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Congenital defects

Lip and palate development:

Upper lip develop by coalescence of the

premaxilla and maxillary growth centers on either

sides to produce the complete lip.

Fusion of the of the lip developing from growth

centers commences around each nostril floor

and spreads downwards towards the lower

border of the lip uniting the premaxilla and

maxillary process in each side.

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Congenital defects

Failure of this union will result in a

cleft lip that varies from a notch on

one side to complete bilateral

cleft of the lip that may extend up

to into each nostril.

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Congenital defects

The palate:

Palate develops from the max. and premix.

growth centers, union of the three segments

commencing at the region of the nasal floor

presented in full development by the nasal

foramen.

Union from this point proceeds backwards until

both the hard and soft palates and uvula have

united, and forwards along the of the future

maxillary and premaxillary structures eventually.

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Congenital defects

• Lack of fusion of the palatal shelves either

completely or partially occurs during embryonic

growth side.

• Failure of union of palatine processes at any

stage will result in a cleft palate which may be

pre-alveolar ( cleft lip ) or post alveolar ( cleft

palate ) .

• Cleft palate between 6th – 9th wk. of the

embryonic life.

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Congenital defects

Classification of cleft palatePre-alveolar e.g. cleft lip

Post alveolar any cleft from uvula up

to incisive foramen.

Alveolar cleft extending from uvula

to alveolar ridge and lip either

unilateral or bilateral.

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Congenital defects

Effects of cleft palate and lip

1. Speech – lack of valvopharyngeal closure leads

to escape of air through the nose (nasal speech)

2. Deglutition – greatly impede the feeding,

regurgitation and escape of fluids through the

nose takes place .

3. Mastication – impaired due to escape of food

through the nasal cavity and due to missing

teeth and malocclusion .

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Congenital defects

4. Esthetics – is effected seriously

especially in cleft palate and / or lip.

5. Deterioration of the general health

6. Psychological trauma .

7. Recurrent infection of the air ways

and middle ear .

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Congenital defects

Management of cleft lip and palate Include the following:

A. Surgical closure

It is the treatment of choice for palatal cleft closure. It

superior to prosthetic closure by obturator.

If cleft involves the lip, it is advisable to repair it as early as

possible (6 wks. after birth) to facilitate feeding and

improve appearance.

Surgical closure of palatal cleft is better to be done

before the end of the second year of age.

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Congenital defects

B. Prosthetic restoration

o Feeding appliances.

o Simple palatal plate to close cleft.

o Speech aid obturator.

o Over denture.

C. Orthodontic

o To correct the malaligned teeth or expand the maxillary

arch.

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Congenital defects

Reason for early closure of cleft palate

1. To produce longer and more mobile soft palate

with better muscular development and

2. velopharyngeal closure.

3. To habilitate the patient for normal speech.

4. To allow undisturbed growth of maxilla.

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ACQUIRED PALATAL

DEFECTS

DEFINITION:

Lack of continuity of originally intact palatal

structures through the whole or part of its length.

Etiology:

Surgical e.g. tumor removal.

Traumatic fracture of maxilla.

Pathological conditions e.g. osteomyelitis, T. B.,

and syphilis .

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ACQUIRED PALATAL DEFECTS

Prosthetic rehabilitation of acquired maxillary defect:

The main priority for the patient with traumatic injury and

traumatic surgery is to stabilize the patient and control

immediate damage and/or defect.

Three phases of prosthodontic treatment includes:

Surgical procedures + Immediate obturator.

Transitional obturator.

Definitive obturator.

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IMMEDIATE OBTURATOR

IMMEDIATE OBTURATOR

1. It is a prosthesis inserted immediately after operation

2. Lasts 10-14 days after surgery

3. Material used, mostly acrylic

ADVANTAGES:

1. Maintain function (feeding, speech)

2. Promote healing

3. Restore esthetic

4. Act as stint (keep surgical pack and medication close to the wound)

5. Improve psychology of the patient

6. Prevent contamination of the wound

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IMMEDIATE OBTURATOR

Construction:

o Impression/construction of the cast models.

o With the help of the surgeon determine the area to be

removed on the cast .

o The appliance is constructed as a plate to close the

operation site.

o Prepared cast is waxed, processed using either heat or

cold curing resin and wire clasps to retain the obturator.

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IMMEDIATE OBTURATOR

o During operation eradication of the

involved area, and surgical cavity is

filled with surgical pack.

o We can say, it is simple plate with no

teeth and constructed before surgery

to be inserted immediately after

surgery .

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Temporary Obturators

Temporary/Transitional Obturator:

Constructed few days after operation

to help in restoring oro-nasal function.

Carries teeth and stays 3-6 months.

Making impression is complicated by

presence of the wound and presence

of the defect.

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Temporary Obturators

The defect is packed with gauze

dipped in Vaseline to the level of

the remaining tissue, then

impression is taken with modified

stock tray using elastic impression

material.

The steps of construction are the

same as in immediate obturator.

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Temporary Obturators

Function: helps in restoring

1. Speech.

2. Feeding.

3. Esthetics.

4. Prevent wound contamination.

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Definitive Obturators

Definitive Obturator:

It is a final prosthetic management

construction after complete

healing of the operation site .

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Definitive Obturators

Preparation of the mouth for obturator:

I. Extract hopeless teeth.

II. Periodontal therapy.

III. Restore carious teeth.

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Definitive Obturators

Types of obturators:

1. Hollow bulb (Closed).

2. Roofless (Open bulb).

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Definitive Obturators

Construction:

1. Select stock tray, modified with wax

according to the size and shape of

the defect.

2. Partially, pack the defect with

Vaseline gauze, then do primary

impression using alginate.

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Definitive Obturators

3. Under cuts are lift to help in retention. Gauze

can prevent broken pieces of alginate from

escaping into the defect.

4. Construct sp. Trays and do final impression using

alginate or rubber base impression material.

5. Outline the master cast to mark the bearing

area, blocking severe undercut, leaving small undercut area for obturator retention.

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Premaxilla Preserved 37

Premaxilla Preserved

Cut through tooth socket

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Mucosa Not Preserved

Rough edge uncomfortable for patient

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Obturator

Restores oro-nasal

partition.

At times can be

added to prior

dentures.

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Skin Grafting of Defect

Less pain while healing.

Less contracture of scar band

which obscures cancer

surveillance.

Accomodates obturator better.

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Maxillary Prosthesis

Articulates with scar

band.

Hollowed to be

lightweight.

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Maxillary Prosthesis

Can be made

with a reservoir

to hold artificial

saliva.

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Timing

Immediate (Intraoperative)

hold in packs

provide early function

Interim

Definitive

3 to 6 months

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Prosthetic Materials

Acrylics

Polyurethanes

Silicone Elastomers

Room-temperature

vulcanizing

High-temperature vulcanizing

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Mandible

Mandibular reconstruction

revolutionized by microvascular and

plating techniques.

Prosthetics mainly restore occlusion and

occlusal surface.

Implants able to restore high degree of

function.

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Mandible

Skin graft preserves alveolar ridge for denture support

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Postoperative Malocclusion

Deviates to surgical side

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Maxillary Ramp49

Maxillary Ramp50

Guide Plane Prosthesis51

Guide Plane Prosthesis52

Adjunctive Preprosthetic

Measures

Vestibuloplasty.

Lowering of Floor of Mouth.

Implants.

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Vestibuloplasty54

Lowering the Floor of

Mouth

Goal is to reposition mylohyoid muscle.

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Lowering the Floor of

Mouth

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Edentulous Mandible57

Mental Foramen

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Implants59

Implants

Branemark in the 50’s studying

bone temp during drilling.

Found temp probes couldn’t be

removed from bone without

fracturing.

Led to study of osseointegration.

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Implants

Made of titanium.

Have to be drilled at low speed.

Oxide on metallic surface is

dipole.

Plasma proteins adhere.

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Implants

Implant placed first -- closed primarily

Abutment placed 4-6 mo later

Appliance attached

rigidly

removable

samarium-cobalt magnets

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Implants

Factors that influence success

material

macrostructure

microstructure

implant bed

surgical technique

loading conditions

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Implants

Implants can be placed in grafted

fibula.

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Implants

Want to avoid large step-off if

possible.

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Extraoral

Prostheses

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Extraoral Prostheses

General Principles:

Goal is cosmetic.

Retained with :

Adhesives.

Implants.

Skin grafting may help.

Smooth edges.

Extraoral Prostheses Ear:

Retain tragus if possible to camouflage anterior

border.

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Extraoral

Prostheses -- Ear

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Extraoral

Prostheses -- Ear

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Extraoral Prostheses -- Ear

Tragus hides attachment.

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Extraoral Prostheses -- Orbit

Skin graft provides base for prosthesis.

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Extraoral Prostheses -- Orbit

Glasses help hide margin.

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Extraoral Prostheses -- Nose

Skin graft provides base for prosthesis.

Alar tag undesirable.

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Extraoral

Prostheses -- Nose

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Extraoral

Prostheses -- Nose

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Extraoral

Prostheses -- Nose

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Extraoral

Prostheses -- Nose

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Conclusion

Restore function and cosmesis.

Use techniques during surgery to

aid prosthetic management.

Consultation with maxillofacial

prosthodontist for optimal

rehabilitation.

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THANK YOU79