Maxillofacial Notes Dr.mahmoud Ramadan

8/9/2019 Maxillofacial Notes Dr.mahmoud Ramadan

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Maxillofacial Prosthodontics

Short Notes

By

Dr Mahmoud Ramadan

1st Edition

2010

This note book is edited and published by 4Dent Int. Community – www.4dent.org – you are

allowed to share it only for free and you aren't allowed to sell it or to modify it's components

without a written permission from the author and the publisher.


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Maxillofacial Prosthodontics Dr. Mahmoud Ramadan

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Table of contents

Page Subject

2 Table of Contents.

3 Objectives of maxillofacial prosthesis.

3 Types of maxillofacial defects.

4 Maxillofacial team.

5 Diagnosis and treatment planning .

7 Congenital cleft palate.

20 Congenital cleft palate.

31 Maxillofacial Splints.

40 Maxillofacial Stents.

58 Radiation and Radiotherapy prosthesis.

63 Acquired Mandibular Defects.

71 Facial Impression.

73 Nasal Prosthesis.

76 Occular Prosthesis.

79 Cranial Prosthesis.


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Introduction

Objectives of maxillofacial prosthetics :1. Improve or restore the esthetics or cosmetic appearance of the patient which is of prime

importance for every body .

2.

Improve or restore the functions that include :

a. Speech function in patients with cleft palate .

b. Nutritional function in patients with lost parts of the jaw .

c. Avoid the escape of food to the nasal cavity . In children with cleft palate trying to

overcome the feeding problem and help to maintain the child general health .

3. Protect the tissues :

To protect the adjacent tissues as in the radium protective shield , also to protect wound , stop

bleeding and carry medicaments after surgery . In contact sport mouth guards are used to

protect the teeth against possible injuries .

4- Therapeutic or healing effect :

Placement of appliances such as the radium needle , carrier stents and splints which are used toaid and promote the healing process .

5- Psychologic therapy :

To raise the morale of the patient which is very important for such type of patient .

Essentials of maxillofacial Prosthesis:

The maxillofacial appliance must meet certain requirements :1- The appliance must be easily seated in place comfortably and securely as mush as possible .

2- The appliance must be durable and easily cleaned .

3- The material used must be easily adjusted and altered if needed .

To attain these goals each patient must be treated individually .

Types of Maxillofacial defects :There are three types of maxillofacial defects .

I. Congenital :- e.g. cleft palate , cleft palate , cleft lip , missing ear , prognathism .

II. Acquired : Accidents , surgery , pathology .

III. Developmental : Prognathism , Retrognathism .

Classification of Maxillofacial Restorations :Maxillofacial restorations can be classified into different groups or phases according to its site

into :

I – Intra – oral restorations :

a. Obturators :

Used in patients with congenital or acquired cleft palate .

b. Stents :

Used in different forms e.g. Antihoemorrhagic stent , mouth protectors and Radium carriers .

c. Splints :

Used in cases of fractures to hold fragments .

d. Resection Appliance :

Used in cases of mandibular defects to correct its continuity ( closure of the mandible ) .

II. Extra – oral restorations :

a. Radium shield : Used in cases of radiation treatment to protect unaffected areas .

b.

Restoration of missing eye , missing nose or missing ear .c. Ear plugs for hearing aids .

III. Combined intra – Oral and extra – oral restorations :

Used in case where there is lost part of the maxilla or mandible with the facial structures .


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IV. Cranial and facial restorations :

a. Cranial onlays & Inlays : used in cranioplasty to compensate for lost cranial bone due to

skull injury .

b. Intra – mandibular implants : used to restore lost part of mandibular bone with acrylic

or metal part .

Maxillofacial team :Team is a group of people working to achieve certain purpose . The members of the team must

cooperate in every way to fulfill their goal :

The member the team furtria as a unit .

The maxillofacial prosthodontist serves primarily as a member of a team and must cooperate

with the other members in planning rehabilitative treatment for patients with maxillofacial

defects ( The members of the team function as a unit ) . Every member should have some

knowledge in other specialties .

Members of the maxillofacial team :

1- Plastic Surgeon :

Plays the most important part when surgical correction and rehabilitation of the deformity is theproposed and favorable line of treatment . Correction of hare lip is usually done surgically . Also

correction of congenital palatal defects is done surgically in most cases .

2- Speech therapist :

The speech therapist plays an important role in rehabilitating patients with maxillofacial defects

. He often works closely with the prosthodontist in the design and fabrication of the appliance .

The responsibility of the speech therapist is great and is essential after surgery or prosthetic

restoration . The patient must be trained to articulate the words normally .

3- Radiotherapist :

Treating cancer of the oral regions with radiation or radio – agents requires close cooperation

between the radiotherapist and the dentist . Radium source carriers are often required to control

the radiation at the site of the lesion radiation is sometimes combined with surgery .

4- Dental specialists :

A. Prosthodontist :

In inoperable cases , prosthetic appliance may be the only way to help in rehabilitation of facial

injury . When surgery is contraindicated or failed and when surgery is postponed for some time ,

prosthetic management is called for . The prosthodontist should be the most knowledgeable

member of the team charged with management of the patient , not only about the actual

mechanics and construction of the prosthetic device but also about disease under treatment . The

prosthodontist relationship with the oral surgeon must be intimate to be able to offer better

service to the patient . One of the common situations in which the oral surgeon needs the help of

the prosthodontist is in the design and fabrication of immobilization appliances for jawfractures.

B. Orthodontist :

Plays an important role and he is almost invariably required in management of malocclusion in

cleft lip and palatal cases . In such situations the child must be checked orthodontically especially

in the period of mixed dentition .

C. Oral surgeon :

An important of the team for treatment and also for planning the steps for rehabilitation . Also

he may be called upon for any extractions in the field of irradiation .

D. Dental technician :

For the construction of various maxillofacial and surgical prosthesis . Dental technician needs

special skill and training .E. Other dental specialists :

1- Pathologist will be of value in the diagnosis of oral lesion particularly those involving the

odontogenic and salivary gland tissues .


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2- Periodontist help to maintain periodontal health .

3- Pedodontist should be consulted for problem involving children .

5- E.N.T. ( Ear , Nose & Throat ) Specialist :

Important to check hearing acuity and to treat the common symptoms associated with the cleft

palate patients .6- The psychiatrist :

The patient's rehabilitation cannot be considered complete until he is emotionally conditioned to

accept his deformity , the appliance and prospects of recurrence of disease .

The psychiatrist tries to make him accept the problem with healthy attitude , and gain the

patient cooperation in the course of treatment .

7- Social worker :

The social workers have special skill and training for the management of stress and this is of

importance for such patients .

Contraindications of surgery in maxillofacial defects :

1- Advanced age of the patient :This is specially true when the surgical treatment requires multioperations.

2- Poor health :

When general health makes surgical procedures dangerous e.g. cardio – vascular disease , heart

disease and diabetes and also if the general anaesthesia is contraindicated .

3- Very large deformity :

When anatomic parts of head and neck are not replaceable by living tissues and if is not

practical to attempt a grafting procedure .

4- Poor blood supply :

On postradiated tissues and due to unhealthy vascular condition at the site of deformity .

5- Susceptibility to recurrence of malignant lesion .

6-

Expenses of the operation .

Indications of maxillofacial prosthesis :1- When plastic surgery is contraindicated for one or more of the above mentioned reasons .

2- When recurrence of malignancy is expected , the prosthetic restoration is preferred .

3- When radiotherapy is being instituted , radium appliance and radium protector shield can be

used .

4- When displacement of fractured facial bones occurs .

5- Temporary M.F. Prosthesis can be used when plastic surgery requires various steps .

6- When cleft palate is not repairable by surgery .

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For esthetics in prognathic or retrognathic mandibles .

Diagnosis and treatment planning :Patient referred for maxillofacial rehabilitation requires the same thoroughness and attention

afford the regular dental patient seen in the dental office . Their management may be further

complicated by prior surgery and / or radiation therapy .

The diagnosis includes :

1- Dental History .

2- Chief complaint .

3- Physical examination .

4- Aids of diagnosis including laboratory investigations x-ray and study casts .


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Treatment plan :

Treatment should be mainly directed to :

1- To cure or control the disease and to prevent further disability . The prime consideration in

all aspects of rehabilitation procedure is to insure the patient that he remains free of

recurrence .

2-

The objective of the total plan should contribute to the patient's well being and acceptance byhis society .

3- Each member of the team should know the overall objectives and the service to be rendered

should be closely coordinated . Arrangement for patient return at appropriate intervals to his

dentist for routine dental care and to his physician for regular health care must be

considered .

4- Maxillofacial prosthetic treatment is established – after final evaluation of the physical and

radiographic finding , analysis of study casts full consideration of the patients needs for the

device and psychologic acceptance of it .

5- The patient should understand the limitations of the appliance and the complications that

may arise .


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Congenital Cleft PalateDefinition:Cleft may be defined as lack of continuity of the roof of the mouth through the whole or part of

its length in the form of a fissure extending anteroposteriorly.

Embryology of primary palate:During the 5

th to 6

th week of embryonic development the primary palate is formed. The

primordial structures give rise to:

1) The upper lip.

2) The anterior portion of the maxillary alveolar process.

3) The premaxilla.

Therefore the primary palate represents portion of the embryonic fronto-nasal process and

maxillary processes.

The union of the different processes begins at the meeting point of the premaxilla and the

two maxillary processes in anterior and posterior directions to end with a (Y) shaped suture. The

union progresses anteriorly along the upper limbs of the (Y) to form the upper lip and maxillaryridge and along the lower limb of the (Y) to form the hard and soft palate.

Etiology:Congenital cleft palate results from lack of fusion of embryological processes which would

normally unite to form the palate during the 6th

and 9th

weeks of the embryonic life along the

lines of fusion. The fusion of the right and left palatal shelves and inter-maxillary process is at

about the 10th

to 12th

weeks.

The exact cause of the clefts is not well known. Some researchers believe that the abnormal

position of the embryo may play a role in inducing the cleft pressure of the amniotic fluid, failure

of the tongue to drop, or persistence of epithelium at the junction of the two palatal alveolar

processes could be the cause of failure of union between the palatal shelves.

Factors that influence the induction of the cleft palate:

1- Hereditary:

The incidence of clefts is greater in the children of parents with deformities.

2- Environmental:

A- Endocrine factors:

Experimentally cleft palate was induced in pregnant mice by injecting cortisone. Also hormonal

disturbance e.g.. pituitary may be an influencing factor.

B- Radiation and x- ray:

Large number of deformities including clefts occur when mothers receive therapeutic radiation

of the pelvis during the early months of pregnancy.C- Nutritional inadequacies:

High percentage of cleft palate could be induced experimentally by controlled dietary deficiency

as vitamin A and riboflavin. Others suggested that the endocrine disturbance occurring with

dietary deficiency might be responsible for the occurrence of clefts.

D- Infection and disease:

Infectious disease of the mother as German measles was thought to induce clefts in children.

E- Stress and disturbances of fetal circulation:

Some studies indicate that anxiety associated with first trimester of pregnancy might cause cleft

since stresses agent influence cortical activity.

F- Chemical irritation:

Mothers exposed to chemical irritation e.g.. hypoxia and hypervitaminosis A.It is more logic to consider the hereditary factor as increased by the environmental factors.


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Classification of cleft lip and palate:Cleft lip and palate were grouped in different categories according to location and / or extent of

the cleft. Different systems of classification have been suggested by different authors.

A) Davis classification (1922).

B) Veau's classification: (1931) still used

Type I: Cleft of the soft palate only.Type II: Cleft of hard palate and soft palate.

Type III: Cleft of both hard and soft palate plus unilateral

Cleft in the alveolar ridge and upper lip.

Type IV: Cleft of both hard & soft palate and bilateral

Clefts in the upper alveolar ridges and upper lip.

C) Stark's classification (1958) (The most widely used today).

D) Olin's classification:

Group I: Cleft lip only ; unilateral or bilateral with nasal deformity.

Group II: Cleft palate only ; part of the soft palate, or the entire soft & hard palates may be

involved.

Group III: Cleft lip and cleft palate involving the alveolar ridge. Patient may have unilateral or

bilateral clefts.

Group IV: Clefts of the lip and alveolar ridge not involving the palate. This condition is of rare

occurrence.

E) Harkin's classification:

Patients are classified according to the degree of the cleft into:

1- Bifid uvula.

2- Cleft of the soft palate.

3- Cleft of soft and hard palate extending through the palatal bones.

4- Cleft of the soft and hard palate extending to the incisive foremen.

5- Cleft of soft and hard palates extending through the alveolar process and lip on one side.

6-

Cleft of soft and hard palates extending through the alveolar process and lip on both sides.

F) Davis classification: (1922) (Not used now) Classification depends on the extent of cleft

Group 1: all clefts of the lip

Group 2: All posterior alveolar clefts.

Group 3: complete cleft of alveolar ridge, palate & lip.

Disabilities (Problems associated with cleft palate): Disability of the cleft palate patient is due to inability to close well the nasopharynx from the

oropharynx.

1- Speech:

1) The inadequacy of the velopharyngeal closure causes air to escape through the nose duringspeech. The result is nasal speech which is unintelligible, calls attention of itself and causes its

bearer to be mal- adjusted.

2) The occurrence of congenital defect presents a more complicated problem than the acquired

defect. In the former condition the normal speech pattern is not formed so even with correction

of the anatomical defect the patient needs speech therapy to break the abnormal pattern first

and to learn normal speech. In cases of acquired cleft palate, the speech returns to normal

immediately after the correction of the defect, because the speech pattern is already formed.

Mechanism of speech & deformities in cleft palate:

For the vowel sounds the air stream escapes continually through the mouth, the shape of

which is altered for various vowels by raising or lowering the tongue and by altering the shape of

the exist through the lips.The oral consonants are produced by air stream being stopped in its passage through the

mouth by the formation of complete or partial seals or stops. These are produced by the tongue


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pressing against the teeth or palate, or by closing of the lips. These called plosive sounds as

P,B,T,D,K and G are made by sudden breaking of the seal brought about by withdrawal of the

tongue or opening of the lips. For example the lip closure of P and B sounds, the tongue and

anterior hard palate contact in T and D sounds.

When the seal or stop is not complete but a channel through which the air stream must pass

is made extremely narrow called faricative. For example S,Z or C are soft sounds in which thetongue separates itself from the anterior aspect of the hard palate forming a thin slit like channel

through which the air stream pass. Fricatives (from friction) the air pass out make friction as in

F,V and Ph labiodental Th, J lingudental fricatives.

Tongue and portion of the hard palate posterior to e.g. (J,CH,SH,L,R) contact of tongue

and nasopalate e.g. Hard K,G and Ng. Nasal sounds M,N and NG as in ring are produced with

the soft palate lowered allowing the air stream to escape through the nose.

2- Mastication:

This function is impaired due to escape of food through the nasal cavity. Also missing teeth

and mal – occlusion frequently complicate the problem of mastication in cleft palate patients.

3- Swallowing:

If both the hard and soft palates are involved, the natural process of swallowing isimpossible and the first problem facing is nursing a child born with a cleft. Breast feeding is

quite difficult due to lack negative pressure in the oral cavity, regurgitation and escape of fluids

through the nose. The position of the baby during feeding should be changed to sitting position

rather than on the back. Special nipples for feeding bottles with flanges to close the palatal gap

should be used.

4- Appearance:

The presence of cleft lip and palate affects the shape of the face. The most common cause of

facial deformity is improper surgical repair of the hard palate. This is due to trauma to the

centers of bone growth and the contraction of scar tissue leading to reduction in the lateral

dimension and forward growth of the maxilla and hence deformity of the middle third of the

face.

In the absence of a labial cleft, maxillary and facial development will often processed

normally. Clefts involving only the soft palate will of course leave no facial deformity.

5- General Health:

The child's health may be affected due to problems of feeding inadequacy of nutrition and

mouth breathing.

6- Psychological:

Most of the children with such congenital defects have problems with adjustment to society.

They might withdraw completely taking negative attitude towards the outside world, or they

may turn aggressive and react violently to others.

Anatomy and physiology of palatal and pharyngeal muscles:Anatomy of the soft palate:

The soft palate is a curtain of soft tissue attached anteriorly to the posterior border of the

hard palate and laterally to the walls of the pharynx. Its posterior border is free with the uvula

hanging from its center.

The soft palate is composed of paired extrinsic muscles entering from side to be inserted

into the soft palate these muscles are:

Tensor palatine muscle:

It originates from base of the skull descends more vertically. They terminate in tendon

which pass around bony hook like process pterygoid hamulus. In contraction it depress the soft

palate make it more tense and thus assists its contact with the tongue.Levator palatine muscle:

It originates on the petrous portion of the temporal bone and the cartilaginous portion of

Eustachian tube. They have downward and forward directions. Their contraction draws the soft


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palate upwards and backwards causes the free margin of the soft palate to touch the posterior

pharyngeal wall as in swallowing or oral breathing.

Palato pharyngeal muscle:

Arising from the posterior borders of the thyroid cartilage pass upward to form posterior pillars

of fauces. They curve inward to enter the palate. Some fibers blend into lateral and posterior

1-

it acts with the tensor to depress the palate against the levator palate in swallowing.2- Raise the back of the tongue.

Pharynx:

The pharynx is a simple, funnel shaped tube wide at the head and narrow at esophageal

end. The pharynx has three muscles superior, middle and inferior constrictors. The constrictor

muscles are so arranged by inter looking fibers that a wave of constricting impulses helps the

food to pass towards the stomach. The upper part of the pharynx is formed by the superior

muscles, this part is concerned with both speech and swallowing. While its lower part is

concerned with swallowing only.

During speech the pharynx is contracted and causes an inward movement of the lateral

walls. In some cases passavant described a horizontal ridge or cushion " Cross roll " around the

lateral and posterior walls of the pharynx at the horizontal level of the hard palate and he calledit passavant's ridge passavant believed that the passavant's ridge is a component of the usual

mechanism of closure during speech that is visible by the presence of a cleft.

Recent studies indicated that the ridge appeared during speech in approximately 10% of

non cleft palate subjects compared with finding of about 50% of unrepaired cleft palate subjects.

Moreover evidence is lacking to suggest that the ridge is a compensatory factor associated with

cleft palate help in reducing the coronal diameter of palatopharyngeal orifice.

Palato Glossus muscle:

They originate from the sides and base of the tongue and curving outward and upwards to

enter the under surface of the soft palate forming the anterior pillars of fauces, and like palato

pharyngeal muscle, unite in the median aponeurosis of the palate to form an inverted (V).

In contraction they have three functions:

1- It acts with the tensor to depress the palate against the levator palate in swallowing.

2- Raise the back of the tongue.

Palatopharyngeal mechanism:The palatopharyngeal valveolar or sphincter functions through the action of several muscle

groups.

At rest, the soft palate drops downward such that the oro-pharynx and naso-pharynx are

opened to allow for normal breathing through the nasal passages. When palatopharyngeal

closure is required, the middle one third of the soft palate arcs upward and backward to contact

the posterior pharyngeal wall. At the same time the lateral pharyngeal walls move medially tocontact the margins of the soft palate. The posterior pharyngeal wall may move anteriorly to

facilitate contact with the elevated soft palate.

Complete palatopharyngeal closure is required for normal deglutition and production of

some speech sounds, such as plosives. For vowels and nasal consonants the palatopharyngeal

part will be opened in varying degrees.

Function of the Palatopharyngeal mechanism:

1- Speech mechanism:

Speech mechanism is divided into five components: respiration, phonation, resonation,

articulation and neurologic integration, also audition and ability to hear sound can be added.

2- Respiration:

Speech is a process initiated by the energy inherent in the stream of air. During exhalation acontinuous stream of air is passed from the lungs (with sufficient volume and pressure) to be

modified in its course by the maxillofacial structures giving rise to the sound.


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3- Phonation:

As air leaves the lungs, it passes through the larynx, whose vocal folds modify the stream of air

by creating resistance to it, set up a sequence of laryngeal sound waves with characteristic pitch

and intensity.

4- Resonance:

The sound waves produced at the vocal folds are amplified. Amplification is by pharynx,oral cavity and nasal cavities.

5- Articulation:

To modify the laryngeal tones and to create new sounds within the oral cavity by tongue,

teeth and lips. The tongue is the most important articulatory structure.

6- Neurologic integration:

The factor for the production of speech are highly coordinated by the central nervous

system. Speech is a learned function as adequate hearing, vision and normal nervous system are

required for its full development.

7- Phonetics:

The voice is principally produced in the larynx, whilst the tongue by constantly changing its

shape and position of contact with the lips, teeth, alveolareoli and hard and soft palates, gives thesound form and influences its qualities. The oral cavity and the sinuses act as resonant –

chambers, and the muscles of the abdomen and thorax control the volume, and rate of flow, of

the air stream passing into the speech mechanism.

The soft palate in conjunction with the pharynx controls the direction of the air stream after

it passes from the larynx. In all the vowel, and most consonant sounds, the air stream is confined

entirely to the oral cavity, but a few nasal sounds do occur, e.g.. M,N and NG, in which the air is

expelled mainly through the nose. The former are produced by raising the soft palate into close

contact with the pharynx, thus sealing off the nose and forcing the air to proceed through the

mouth.

With the nasal sounds the soft palate is pressed downwards and forwards and the dorsum of

the tongue humped up to meet it, thus sealing off the oral cavity and forcing the air stream to

proceed through the nose. The flow, the alteration in size of the mouth and the change in shape,

and size of the lip opening giving the various sounds their characteristic form.

The consonant sounds are produced by the air stream being stopped in its passage through

the mouth by the formation of complete or partial seals or stops. These are produced by the

tongue pressing against the teeth or palate, or by the closing of the lips. The sudden breaking of

the seal brought about by the withdrawal of the tongue, or the opening of the lips, produces the

sound. In many sounds there is a build up of air pressure behind the stop which when the seal is

released produces an explosive effect. Examples of these are: the lip closure of the P and B

sounds ; the tongue and anterior hard palate contact in T and D sounds.

In some cases the seal or stop is not complete, but the channel through which the air streammust pass is made extremely narrow: an example of this is the production of an s, z,or c soft

sound, in which the tongue separates itself from he anterior aspect of the hard palate by about 1

mm., forming a thin slit- like channel through which the air stream hisses.

Speech, therefore, is largely a matter of the control of the size and shape of the mouth,

which is chiefly governed by the position of the tongue and its contact with teeth, alveolareoli

and palate.

Fortunately for the prosthetist, the tongue possesses remarkable qualities of adaptability,

and rapidly becomes accustomed to change occurring in the mouth.

The factors in denture construction affecting phonation:

The Vowel sounds:

These sounds are produced by a continuous air stream passing through the oral cavitywhich is in the form of a single chamber for the (A, O, U sounds and a double chamber for the I

and E sounds), the division occurring through the dorsum of the tongue touching the soft palate

in the post dam region. The tip of the tongue, in all the vowel sounds, lies on the floor of the


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mouth either in contact with or close to the lingual surfaces of the lower anterior teeth and gums.

The application of this in prosthetic construction is that the lower anterior teeth should be set so

that they do not impede the tongue positioning for these sounds, that is, they should not be set

lingual to the alveolar ridge, since the vowels E and I necessitate contact between the tongue and

soft palate, the upper base must be kept thin, and the posterior border should merge into the soft

tissue in order to avoid irritating the dorsum of the tongue, which might occur if this surface ofthe denture was allowed to remain thick and square – ended.

The consonant sounds:

For convenience, these sounds may be classified thus:

a) Labials: Formed mainly by the lips (e.g.. B, P, M).

b) Labiodentals: Formed by the lips and teeth (e.g.. F, V, Ph).

c) Linguodental: Formed by the tongue and teeth (e.g.. Th).

d) Linguopalatals: Formed by the tongue and palate.

(i) Tongue and anterior portion of the hard palate D, T, C (soft), S, z, R).

(ii) Tongue and portion of the hard palate posterior to that of (i) (e.g.. J CH, SH, I, R).

(iii) Tongue and soft palate (e.g.. C (hard), RG, NG)

e) Nasal (e.g.. M, N, NG – also belonging to the other groups).Unless careful consideration is given to the following aspects of denture construction, speech

defects will occur varying from the almost indiscernible to the unpleasantly obvious.

Objectives of cleft palate prosthesis:The prosthesis must establish a competent naso – oral separation to satisfy the following

objectives:

1- Socially acceptable speech:

The prosthesis must help the patient to acquire normal speech pattern. For reasonable speech

articulation and resonance there must be adequate dental relation together with adequate

oronasal separation.

2- Restoration of masticating apparatus:

a. Help in mastication and increases the efficiency of chewing and confine the food material in

the oral cavity.

b. Help in deglutition and prevent the seepage of fluids to the nasal cavity during the act of

swallowing.

3- Prevent the seepage of nasal secretion into the oral cavity.

4- Facial esthetics and dental harmony.

a. Improve the esthetics of the patient.

b. Restoring the missing, malposed and improve the articulation of the teeth to establish dental

esthetics.

5- Improve psychological condition of the patient.

Indications of maxillofacial prosthesis in unoperated cases (speech aid prosthesis):Generally speaking, surgical repair of cleft palate is to be preferred to prosthetic correction by

the speech aid prosthesis. However, there are some situations in which a prosthesis should be the

restoration of choice. Some of such situations are:

1- A wide cleft with a deficient soft palate:

When the cleft is wide and lack the required amount of tissue for the closure to function

properly.

2- A wide cleft of the hard palate particularly in bilateral clefts. Surgical repair may produce a

low vaulted palate. In such cases, it may be possible to close the soft palate with local flaps and

restore the hard palate with a prosthesis.3- When there is partial or complete paralysis of the remnants of the soft palate.


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3- Uncooperative patient and parents.

4- Uncontrolled dental caries:

If caries is rampant and not controlled, a prosthesis of any sort should not be recommended.

5- Lack of trained prosthodontist:

The prosthodontist engaged in the cleft palate rehabilitation should have received adequate

training in cleft palate center. He should be thoroughly familiar with the anatomy andphysiology of the area involved and the basic rules governing fixed and removable partial

denture prosthesis.

Diagnosis and treatment planning:Diagnosis and treatment planning are carried out through the maxillofacial team

representing different specialties.

Full consideration should be given to the following:

1- Type and width of the cleft.

2- Position and relation of the maxillary segments to each other.

3- Form of the maxillary arch and its lateral anteroposterior dimensions.

4-

Length, thickness and mobility of the soft palate.

5- Perforations remaining in the hard and soft palate and labial sulcus after surgery.

6- Posterior and lateral pharyngeal wall activities and size of nasopharynx.

7- Floating premaxilla.

8- Number of missing teeth in line of cleft, malformed and malposed teeth and partially erupted

teeth.

9- Constricted maxilla.

10- Condition of tonsils and adenoids.

11- Growth and development of the child, mental attitude and general health must also be

considered.

12- Speech articulation of the patient, his voice quality and hearing acuity.

Acceptable speech cannot be accomplished without creating proper palato pharyngeal

sphincteric action.

In most cases with cleft lip and palate, surgery on the lip in done in the first few months.

Some surgeons prefer to have the lip repair done even before the mother sees her baby to avoid

the psychological trauma to the mother. Surgical repair of cleft palate if indicated is usually done

when the child reaches 2 years old, although some surgeon prefer to wait until 2 – 6 years.

Preparation of the case for prosthetic treatment:The oral cavity should be prepared before the construction of the speech aid prosthesis as

follows:

1-

Decayed teeth are preferably restored with full coverage to prevent recurrence of decay andto shape the teeth in the desirable form to support and retain the speech aid in position.

2- Every tooth in the cleft palate patient should be, saved to avoid problems of retention.

3- Teeth needing extraction or other surgical treatment should be preferably done before the

construction of the speech aid.

4- Orthodontic treatment to expand the arch or approximate the two segments and correct

malposed teeth is done at this stage if possible.

5- Gingivectomy for partially erupted teeth is recommended to expose the clinical crown to be

used for retention.


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Prosthetic management of cleft palate:

A. Preoperative devices (for children)

1- Feeding devices:Most of infants with cleft lip and palate will be unable to nurse from the breast or ordinary

bottle, since repeated pressure of the tongue on the nipple forces it upwards against the edges of

the cleft and tends to increase the width of the cleft and push parts of the palate upwards.

Since normal suckling and swallowing is impossible, a more upright position of the infant,

and a bottle with the nipple opening slightly enlarged are often all that is needed to aid feeding

and control nasal regurgitation. The wide opening of the nipple will compensate for the slow flow

of milk associated with defective suckling. Some infants with cleft palate may have cardiac and

digestive disorders that may cause the failure of the infant to grow up and increase susceptibility

to aspiration of fluids and also laryngospasm. Nasogastric tube is sometimes used for feeding.

Under these difficult conditions feeding devices can be made in early infancy to facilitate food

intake prior to surgical closure of the palate.

The fabrication of a small palatal prosthesis to obdurate the cleft is indicated so that oral

feeding can be encouraged and the irritation and interference with normal sucking andswallowing movements associated with tube feeding are eliminated. Also it helps to ensure that

adequate nutrition can be maintained.

The feeding appliance consists of an acrylic plate, constructed from a low fusing dental

compound impression. The plate is attached to the neck of feeding bottle to cover the cleft during

feeding. An acrylic plate with a wire handle held by the mother may be used to cover the cleft

during breast feeding.

2- Expansion type prosthesis:These are used preoperatively for complete unilateral or bilateral collapsed clefts, and to

properly align the lateral segment and prepare it for surgical closure with or without bone

grafting. As a diagnostic aid, a transitional prosthesis sometimes indicated to diagnose the needand possible progress in speech to be achieved by certain surgical procedures. In the period of

expansion several successive prosthesis may be needed considering the growth and possible

eruption of the teeth. The expansion sprosthesis is composed of the following portions:

a- Palatal portion:

Composed of two separate lateral sections united by expansion device covering the hard

palate. If this is used in the predental eruption period, it must extend over the alveolar ridge to

the mucobuccal fold. At a later age when the teeth are erupted the prosthesis is extended to the

lingual surface of the teeth. Wrought wire clasps could be added to provide retention.

b- Pharyngeal portion:

Sometimes it is advisable to combine expansion devices with a speech aid prosthesis to

achieve improvement in speech and deglutition simultaneously with expansion.

B. Cleft palate prosthesis for adults:

1- Mobile prosthesis:Delabarre (1820) emphasized the importance of the normal soft palatal movement during

biologic and activities and constructed a prosthesis a soft rubber velar as in the more simple

hinged type obturator. Although these prosthesis were mobile under influence of the cleft soft

palate, the movement was more similar to mechanical movements than to physiologic function.

2- Meatus obturator:

This prosthesis serves a space – filling function. A speech pathologist and dentist teamdesigned the meatus obturator to reduce the resonance of the nasopharynx, particularly in the

lateral regions around the auditory meati. Molding to muscle function was not a feature in its

production.


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3- Fixed pharyngeal obturator (speech aid):This prosthesis has a space filling function in that it is designed to be held in the lower

region of the nasopharynx and is formed to compensate for tissue deficiency. It acts as against

which the palatopharyngeal musculature can form a seal.

In the past, the anterior tubercle of the atlas bone was used as reference point to place the

pharyngeal section. But it was found that its position varies between individuals and in the sameindividual during movement. Again passavant's ridge or pad was considered a reference area for

the pharyngeal portion but it is present in few cases (passavant's ridge coincide with the anterior

tubercle of the atlas vertebra). Recently it was found that in 90% of the individuals, the palato

pharyngeal closure takes place in or above the level of the palatal bone.

Fixed pharyngeal obturator requirements:

1- The prosthesis must be designed to suit the patient regarding his oral and facial condition,

masticatory function, and speech.

2- The prosthesis must preserve the remaining structures wrong design of the maxillary portion

will result in premature loss of the hard and soft tissues and further complicating prosthetic

habilitation.

3- The prosthesis requires greater retention and support. In adult cases, crowing and splinting

of the abutment teeth increases retention and, support.

4- Closed vertical dimension in more suitable in the cleft palate patients.

5- Minimum weight should be kept. The material used should be easily repaired and altered.

6- Soft tissue pressure in the velar and naso–pharyngeal areas by the appliance must be

avoided.

7- The prosthesis must not be displaced by velum, lateral and posterior pharyngeal wall muscle

activities or tongue movement during swallowing and speech production.

8- Pharyngeal section should be properly placed. The superior surface of the pharyngeal section

must be at the level of the palatal plane.

Sections of the speech aid:

The parts of the speech aid are identified with their anatomical structures (Fig. 4-A) to

which they are adapted as follows:

1- The palatomaxillary section:

It covers the cleft of the maxilla (hard palate), contains clasps for retention, and carries

dental replacements when indicated to:

a. Establish functional occlusion.

b. Improve esthetics and facial balance.

c. Increase mastication and deglutition efficiency, and subserve frontal speech needs.

2- The palatovelar section:This section supplements the palatal cleft and must remain in constant lateral contact with

the soft palatal muscles in repose or activity to increase deglutition efficiency and subserve oral

speech purposes.

3- The pharyngeal section:

It extends posteriorly into the pharyngeal cavity in order to be surrounded by the

sphincteric action of the pharyngeal muscles during deglutition and speech.

The extent and dimensions of these sections depend upon the degree of dental and palatal

deficiencies presented, hence each speech aid is different.

For patients with deciduous, mixed or not fully erupted permanent dentition the three

sections of the speech aid are made of acrylic resin, and wrought wire retainers without occlusal

rests. In patients where the permanent teeth are fully erupted, the anterior section should bemade of cast metal or combination of cast metal and acrylic resin.


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pharynx. After one minute, the patient is instructed to swallow some water to register soft palate

muscular movement in the impressions. After the material is set, the prosthesis removed from

the mouth and is sent to the laboratory for processing of the tailpiece.

In order to reduce the number of time the appliance has to be heat – cured, self – curing

acrylic is used for this procedure. I can't seems that limiting the process to two steps is more

feasible to avoid the complication arising from curing the appliance three times, the maxillaryand velar sections could be constructed at the same time a wire loop attached to the end of the

velar section.

The finished tailpiece is inserted into the mouth, and the injection of some water stimulates

the muscle movement along the lateral edge of the velar section. Lateral overextension of the

velar section usually causes undue muscle displacement and eventual tissue soreness. The velar

section should touch the remnants of the soft palate in repose and function.

3- Pharyngeal section (Posterior portion):

Construction of pharyngeal section (speech bulb):

The loop of wire is attached to the end of the velar section and adjusted to the level of

maximum activity of the pharyngeal muscles. The wire should be short 2-4mm from the

posterior wall of the pharynx. In adult patients the level of the pharyngeal activity is superior tothat in children.

Green compound is added around the wire loop to reinforce the wire. Also soft modeling

compound is added on the loop. The prosthesis is inserted with the soft compound in the

patient's mouth. The patient is instructed to move his head up and down and then from side to

side while the compound is still soft. The prosthesis is removed, cleaned, dried, reheated on an

open flame and tempered in warm water, then reinserted in the mouth and the patient is asked

to swallow and to pronounce a strong " Ah ". The patient is instructed to place his chin against

his chest and move his head from side to side. The appliance is checked and stick compound is

used to correct the impression section by the above way.

Impression wax, softened in water at 150 – 160

F for 4 to 5 minutes, is added over the

green compound and then inserted in the patient's mouth. The same movements are performed.

The advantage of the impression wax is that it can stay soft in the patient mouth for half an hour

to give him chance to perform the functional movements. The prosthesis is reinserted a number

of times with gradual adjustment to the speech bulb until the functional impression is made of

the involved area.

During construction of the speech bulb the speech therapist works closely with the

prosthodontist. Ideally, the size of the bulb is adjusted until the patient demonstrates good oral

air pressure for production, and until unwanted nasal resonance is eliminated. At the same time

the patient must be able to breath clearly through his nose and produce acceptable nasal sounds.

A special large flask is used for heat curing the tailpiece into clear acrylic resin.

If the lateral and posterior walls of the pharynx are sensitive enough to produce a gagreflex, no attempt is made to obtain a functional impression for the speech bulb. The speech bulb

is constructed under extended in self curing resin at the beginning, and let the patient to use the

prosthesis for two or three weeks. After the patient is accustomed to the undersized bulb, a final

impression of the speech bulb is processed from heat curing.

The speech appliance is inserted in the patient's mouth and checked for the following:

1- Muscle adaptation of the speech bulb during swallowing and phonation.

2- Excessive pressure against the posterior and lateral walls of the pharynx.

3- Stability of the appliance during function.

4- Improvement of voice quality and articulation of speech.

Cleft palate speech aid repair:If the speech aid bulb need repair without any alteration of the anterior part, the

conditioning material is applied to the bulb portion. The bulb portion is then duplicated into

clear acrylic resin.


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The tissue conditioning material is far superior in making the pharyngeal impression. The

patient have the opportunity to use the speech aid at home normal conditions. Whereas in the

clinic the patients tend to exaggerate the movement which leads to inaccurate impression.

4- Silicone retentive obturator:

Indications:a) Congenital clefts.

b) Acquired defects.

c) More retention is required.

Material: Silicone or rubber latex.

Technique of construction.

5- Palatal Lift Prosthesis (Improve speech):

- Soft palate of sufficient length but lack of sufficient mobility due to muscle paralysis.

- Lift the soft palate to contact the palato pharyngeal wall.- Maintain some opening on the sides of the elevated palate for nasal breathing.

6- Fixed Prosthesis (Stabilize Premaxilla).

7- Snap-on Prosthesis:

Types:

a) with speech pulp. b) without speech pulp.

8- Unconventional speech aid prosthesis:

Two sections: Nasal portion – Denture.

9- Titanium self tapping implants:

Position: Alveolus – Ptrygoid plates.

9-

Root coping (attachments) Telescopic crown with rest.


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Acquired Cleft PalateWhile congenital clefts are confined to the lines of union of the different embryonic

processes of the palate, the acquired clefts (some times called fenestration can occur any where

in the palate in various sizes. The defect may involve the alveolar process, tuberosity, the hard

and/or the soft palate.

Etiology of acquired clefts:1- Trauma: From a sharp instrument or pencil, from gun – short or in cases of comminuted

fracture of the maxilla.

2- Disease: As in tuberculosis, syphilis, osteomyelitis of the palatal bone, cancer and suction disc.

3- Surgical operation: Surgical removal of tumors (malignant or benign) involving the palatal

structures.

Disabilities:Nearly the same as in congenital clefts.

1- Speech: Although speech is changed after surgery but ensure the patient that such a defectwill be corrected after insertion of the prosthesis.

2- Appearance: This is the big problem. Diplopia may result in resected maxilla due to lowering

of the eye to removal of the floor of the orbit.

3- Mastication: Food regurgitation through the nose is a problem.

4- Psychologic considerations:

Rehabilitation of acquired cleft palate:

1- Surgical reconstruction:It is the best line of treatment but it has it's limitations. It is indicated in the following cases:

1) If the defect is the result of trauma.

2)

If the size of the defect is small.

3) No susceptibility of recurrence.

2- Prosthetic rehabilitation:Is indicated in the following cases:

1) Large defects that difficult to be corrected by surgery.

2) When there is likelihood of recurrence.

3) Large soft palatal defects as they are difficult to restore surgically to normal function.

Prosthetic therapy for patients with acquired surgical defects of the maxilla can be divided

into two phases of treatment:1- Initial phase called surgical obturation entails the placement of a prosthesis at surgery or

immediately there after. This prosthesis must be modified at frequent intervals to

accommodate for the rapid soft tissue changes that occur within the defect during

organization and healing of the wound. It's objective is to restore and maintain oral functions

at reasonable levels during the postoperative period until healing is completed.

2- Second phase of prosthetic therapy. Starts 3 – 4 months after surgery at which time surgical

site becomes stable dimensionally permitting construction of the definitive prosthesis.

Surgical obturation:Surgical obturation can be carried out with a variety of materials and restorations e.g.

sponges, gutta-percha and acrylic resin prosthesis. Acrylic resin prosthesis is more superior andis our concern.


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Obturation may be accomplished with the placement of an immediate surgical obturator at

surgery or with the placement of a delayed surgical obturation six to ten days post-surgically.

Immediate Surgical ObturationThis type of obturator is well suited for dentulous patients requiring a partial or total

maxillectomy because the remaining teeth can be used to help retain the prosthesis in position.

Advantages of the immediate surgical obturation:The rationale for using the maxillary immediate surgical obturator prosthesis is threefold:

1- Functional: the prosthesis act as a matrix for the surgical dressing placed in the maxillary

defect. It also permits the patient to speak and swallow more normally upon awakening from

anesthesia. It allows earlier removal of the nasogastric tube.

2- Hygienic: the obturator separates the maxillary surgical site from the contents of the oral

cavity. Reduce the oral contamination of the wound and hence the liability of infection.

3- Psychological: the obturator prosthesis restores the patient's self – image by reproducing the

contours of the lost oral structures and allowing the patient to function in a socialenvironment. It lessen psychologic impact of surgery. It helps to reduce period of

hospitalization.

Preoperative guidelines:- A good working relationship with the surgeon will permit ample time for patient evaluation

and treatment. Patient evaluation includes the following data:

a) Medical history: A history of the patient illness as well as the past medical history will provide

clues to potential problems in future care.

b) Dental history: the dental history can be obtained from the patient directly or in conjunction

with clinical observation. The patient's dental hygiene and previous experience with dental

prosthesis should be noted.c) Comprehensive clinical and radiographic examination: this examination will confirm or deny

the patient's dental history and provide information useful in planning the patient's prosthetic

rehabilitation.

d) Diagnostic casts: Impressions are made in irreversible hydrocolloid to provide both diagnostic

and working casts. Inter-occlusal records and mounting the casts on a suitable articulator are

required for proper analysis.

e) Photographs: Photographs provide an excellent record of preoperative conditions.

- Immediate surgical obturator are fabricated on maxillary casts obtained before surgery. The

patient must be seen before surgery for impression making to construct the immediate

surgical obturator. It is in the form of a simple acrylic plate with no teeth and carryingretaining clasps. Retention of the plate in the mouth is by clasps, ligation to the teeth, wiring

to the teeth or pinned to available bone (in edentulous subjects or when the number and

distribution of the remaining teeth is not suitable for retention).It is inserted immediately

after surgery and while the patient is still in the operating room. It must not be removed

before seven to ten days post-surgically.

- The prosthodontist must be informed a reasonable time before operation to give chance for

construction of the surgical obturator the surgeon and the prosthodontist should discuss the

extent of the operation and draw a diagram on the lines of surgical incision (better on the

cast if it available at this time).

Principles relative to the design:


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1- If it is possible persuade the surgeon to leave the posterior edge of the hard palate and

tuberosity. Otherwise the soft palate will be flabby and often drop inferiorly and will exhibit

little motion during the immediate post – operative period.

2- The surgeon is encouraged to make the anterior incision through the socket of an extracted

tooth instead of between adjacent teeth. This will help to preserve the periodontal tissue of

the remaining tooth and minimize the risk of amputating its root. The surgeon should also beinformed if any of the planned incision will involve a fixed restoration. Sectioning the

restoration may be done before surgery on the dental chair to decrease operative time under

general anesthesia, but may contribute to patient apprehension and discomfort prior to

surgery.

3- The obturator should terminate short of the skin graft mucosal junction. When surgical

packing is removed extension into the defect may be accomplished with tissue conditioning

material.

4- Prosthesis should be simple and light in weight.

5- Prosthesis should be perforated at the inter-proximal extensions to help wiring to the teeth at

the time of surgery.

6-

Normal palatal contours should be reproduced facilitate speech and deglutition.7- No posterior occlusion at the defect side.

8- Old dentures if available can be used after their modification. Reduce the flange at the defect

side and remove posterior teeth. The surface should be improved for better retention by the

addition of tissue conditioning material before surgery.

9- Add a couple of wire loops at the fitting surface where the growth is going to be excised (cases

where the growth is big).

Preoperative dental procedures:While planning the maxillary immediate surgical obturator prosthesis, the design of the

interim and/or definitive prosthesis should be planned. The following factors must be

considered:

1- Tooth analysis and their modification:

Abutment teeth and their contours should be identified. If retentive undercuts do not

appear to be adequate, tooth modification should be considered, which may include recontouring

"dimpling" or placement of restorations. Modification should be accomplished at this instead of

at the insertion of the definitive prosthesis. The occlusion may require modification to

accommodate rests and/or clasp of the definitive obturator. The patient should be informed of

these procedure initially. Tooth modifications are easily accomplished at this time than after

surgery.

2- Mold and shade selection:

Mold and shade selection can be accomplished at the initial visit so that the definitiveobturator can be made more esthetics by having the anterior teeth in place.

Technique of construction:1- Tray modification: stock trays may be modified to accommodate the size of the tumor. The

tray may be extended posteriorly to record a significant part of the soft palate if affected.

2- The patient should be placed in an upright position, so that the soft palate will assume a

normal and relaxed position. To overcome the problem of gagging associated with impression

making topical anesthetics may be used and it is preferable to use rapid setting hydrocolloid.

3- Upper and lower alginate impressions are made. It is important to make accurate

impressions of the vestibular depth on the unresected side.

4-

Casts are poured in stone plaster. The upper cast is duplicated for future reference. It may bebetter to make more than one upper impression to give chance for selection. Mount the casts

on an articulator with the aid of a jaw relation record.


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5- After discussing the surgery, the surgeon and prosthodontist will outline the proposed

surgical margins on the upper cast. The lateral boundary is usually the labial and buccal

reflection, and the median boundary is the midline of the palate. The questionable extensions

are the anterior and posterior margins.

6- The maxillary cast is altered to conform to the proposed surgical resection. Teeth to be

included in the resection are removed from the cast, but the alveolar height maintained. Theresidual alveolar ridge is trimmed moderately on the labial and buccal surface to reduce the

stress on the soft tissue closure. Any elevation on the cost denoting the swelling should be

removed to have a normal palatal contour. The cast should be modified so that an adequate

thickness (approximately 2 to 3 mm) of acrylic base will not create occlusal interferences the

cast should be reduced to the level of the palatal cusps. This will allow an adequate thickness

of acrylic resin to mimic the natural palatal contours without impinging laterally or

anteriorly on the surgical flap. The cast in the region of soft palate resection should be

reduced to the level of the hard palate. This will result in the obturator prosthesis being

posterior and superior to the natural drape of the soft palate and minimize impingement on

the tongue during speech and swallowing.

7-

Wire retainers (wire clasps) are prepared on the standing teeth.8- Waxing up of the obturator is carried out. An upper base palate (double thickness of base

plate wax) is adapted to the modified palate and ridges. In patients with excessive vertical

overlap, the obturator extension anteriorly must be thinned to avoid occlusal interference

with mandibular anteriors. Edentulous upper jaws can be retained by wires to the zygomatic

bone.

9- The waxed up obturator is invested, processed in clear acrylic resin finished and polished.

Clear acrylic resin is preferred because it makes it easy to see extensions and pressure areas

during surgery. Holes are drilled in the buccal flanges when it is supposed to be wired to the

zygomatic bone.

10- Wire loops (two) are fixed to the fitting surface of the obturator at the site of surgery with

self curing resin. This wires will help to retain compound in cases of big tumors.

11- Now the obturator is ready for insertion in the surgical room put the obturator in an

antiseptic solution. In most instances the immediate surgical obturator is easily fitted and

secured. Care is taken to adjust the lateral extensions of the obturator short of the skin graft

mucosal junction to avoid pressure to this area. The lateral and anterior aspects of the

prosthesis should be reduced until correct facial contours are obtained without creating

excessive tension during closure.

12- Now, this is the time for molding the compound, or tissue conditioning material to the

surgical wound. Green stick compound is softened in warm water and attached to the wire

loops. The plate is seated in position in the patients mouth after blocking the deep undercuts

with vaselinied gauze. The plate with the compound is removed and reseated in the patientsmouth several times while the compound is still soft to prevent it's anchorage to undercuts of

the surgical wound. Cheek manipulation can help in molding the material while it is still soft.

N.B. A skin graft taken from the inside of the arm may be applied to the surgical wound

(skin grafting) in this case the skin graft is spread on the surface of the compound with it's

raw surface upwards helping to maintain its contact with the walls of the surgical wound.

13- If the surgery is more extensive than planed it is preferable to add a lining material (e.g.

tissue conditioning material) to the prosthesis.

14- In dentulous patients retention can be obtained by clasping or wiring to existing teeth. A no.

8 round bur is used to create openings for every available inter-dental space. Thus, to achieve

stability and retention, many teeth can be ligated to the time of surgery. In edentulous

patients the prosthesis is wired or pinned to the alveolar ridge and/or zygomatic arches.Ligation wire openings should be placed as high as possible on the buccal and palatal aspects

of the remaining alveolus to assure sufficient bone for placement of the ligation wire through

the alveolus. These openings should be connected by a recess into which the ligature wire will


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be placed. This recess will run mesiodistally between the inter dental wire for the dentulous

patient or labio (bucco) palatally for the edentulous patient. This will prevent the ligature

wire from irritating the patient's tongue.

15- The prosthesis and packing are removed after seven to ten days post – surgically. The

prosthesis is cleaned from blood clots and nasal secretions and any necessary adjustments are

made.e.g.:

- Adjustment of wire retainers.

- Minor occlusal discrepancies on the intact side.

- Application of tissue conditioning material to improve adaptation seal and comfort.

- Modification of the compound if present.

16- The patient is then recalled weekly for any necessary adjustment, until he has no trouble

(may be one or two months).

Delayed Surgical ObturationIt is placed seven to ten days after surgery. If the patient is edentulous, and the surgical

defect is to be extensive, this approach may be the treatment of choice.

When the surgical packing is removed from the wound a maxillary impression is obtained

with hydrocolloid. The surgical area will be tender and the patient will be apprehensive, thus

this step must be accomplished with great care. The impression must record as much of the

lateral portion of the defect as is possible.

A soft metal edentulous tray is altered so that 1/4 inch clearance exists in all dimensions. In

the area of the defect it may be necessary to remove of the flange of the tray or to bend it

medially. All flanges are covered with peripheral beading wax and additional wax is added in the

area of the defect to provide support for the impression material. Major medial undercuts are

generally not useful and should be blocked out with vaselinised gauze.

Sensitive areas should also be blocked out. The gauze can also be used to limit the extension

of the impression material into the defect. Impression material should be placed on the lateral

side of the tray corresponding to the defect to record the contour of the lateral cheek surface.

The tray is positioned, seated and the cheeks and lips manipulated especially on the defect

side. The impression will cause pain on removal and it should be released gently. The impression

in then inspected for proper extension and adaptation.

If the patient is dentulous the prosthesis is constructed as described in the immediate

surgical obturator. It is delivered and adjusted using pressure indicator paste and articulating

paper. If it fits well and well retained, it is not necessary to add temporary lining material. As

healing progresses, posterior occlusal ramps can be established with the addition of self curing

resin. Posterior occlusion helps the patient to retain the prosthesis in position. Follow up the caseas in the immediate surgical obturator.

In edentulous patients it is preferable to use the patient's own maxillary denture (if present)

as a delayed surgical obturator. The existing denture should be inspected to ensure that it will

adequately obturate the surgical defect. The buccal and/or labial flanges of the denture are

shortened on the side of the defect. It may be necessary to extend the denture with self curing

resin to cover the margin of resection on the soft palate. After adjustment it is lined with a reline

material.

To summarize we can say that objective of immediate and delayed surgical obturation is to

serve the patient through the immediate postoperative period. In most cases it can be maintained

until the definitive obturator is constructed.

A definitive prosthesis is not indicated until the surgical site is healed, dimensionally stableand the patient is prepared physically and psychologically for the restorative care that may be

necessary.


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Definitive ObturationConstructed three to four months after surgery. The suitable time will vary depending on:

1-

Size of the defect.2- Progress of healing.

3- Prognosis for tumor control.

4- Presence or absence of teeth.

5- Effectiveness of the present obturator.

The defect must be engaged more aggressively for edentulous patients to maximize support,

retention and stability. Thus the recovery period is longer for these patients. Changes associated

with healing and remodeling will continue to occur in the border area of the defect for at least

one year (in edentulous patients) by this time the mental outlook of most patients will be

improved.

Treatment planning:To suggest the line of treatment we must have information about:

1- Prognosis for tumor control.

2- General health of the patient.

3- Data from mounted diagnostic casts.

4- Radiographs for questionable teeth.

5- Desires of the patient from that treatment and his expectations.

Treatment concepts:Several concepts will be discussed now regarding the definitive obturator:

1- Movement of the obturator:The obturator will move during function, if the maxillary alveolar ridge and teeth are

involved in the resection. It will be displayed superiorly with the stress of mastication and will

tend to drop without occlusal contact. The degree of movement and size and configuration of the

defect. The patient must be warned about this problem.

2- Tissue changes:

Dimension change of the defect will continue to occur for at least a year secondary to scar

contracture and further organization of the wound. Also movement of the obturator during

function may contribute to tissue changes. The obturator portion should be acrylic to facilitate

the possibility of rebasing or relining.

3- Covering prosthesis:

Obturator for acquired clefts of the maxilla are basically covering prosthesis serving toestablish the oral – nasal partition. The contours of the defects are relatively static during

function.

4- Extension into the defect:

The degree of extension into the defect is dependent on the requirements of retention,

stability and support. If these properties can be obtained from the remaining maxillary

structures, the extension into the defect need not to be extensive. Mostly, the defect must be used

to improve these qualities. Again extension of the prosthesis into the defect will vary according to

the configuration of the defect and the character of its lining tissue. Extension superiorly along

the nasal septum offers little mechanical advantage as the pseudo-stratified columnar epithelium

lining the nasal septum and other nasal structure will tolerate little stress. In contrast, extension

superiorly along the lateral margin of the defect will enhance retention, stability and support.

Stress is well tolerated by the skin graft and oral mucosa lining the cheek surface of the defect.

In edentulous patients the defect must be used more extensively for retention, stability and


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support. The use of the defect for dentulous patients will vary depending on the size and

configuration of the defect and the number of teeth remaining. If the prosthesis is not properly

designed and constructed, the stress on the remaining hard and soft tissues can be pathological

and can lead to premature loss of abutments and irritation of soft tissues.

5- Teeth:

Presence of teeth enhances the prosthetic prognosis.6- Weight:

Bulky areas should be hollowed to reduce weight to avoid unnecessary stress to the teeth

and supporting tissues. There is controversy whether the supporting surface can be left open or

should be closed. If the obturator is left open, nasal secretions accumulate leading to bad odor

and added weight. On the other hand open obturator has less weight and is easier to adjust. For

drainage a small diagonal opening is made between the inferiolateral floor through to the cheek

surface for drainage. The cheek will close against the opening so the seal is not compromised.

However, sealing the top of the obturator is of advantage if the patient complains of

accumulation of secretions.

Edentulous Patients with Total Maxillectomy DefectWith any sizable palatal perforation retention in the classical sense of complete dentures is

impossible. Air leakage, poor stability & reduced bearing surface will compromise adhesion,

cohesion and peripheral seal. Therefore, the contours of the defect must be used to maximize the

retention, stability and support. The surgical defect should be well healed before fabrication of

the definitive obturator.

Maxillary obturator prosthesis in edentulous patients will exhibit varying degrees of

movement depending on the amount and contour of the remaining hard palate, the size, contour

and the lining mucosa of the defect and the availability of undercuts. During mastication the

prosthesis moves superiorly into the defect. With the release of occlusal pressure, the prosthesis

drops in the opposite direction.

In edentulous patients with a total maxillectomy defect, the axis of rotation is located along

the medial palatal margin of the defect. The portion of the obturator most distant from this axis

will exhibit the greatest degree of motion. In a posterior maxillary defect, where maxillary

segment is retained the axis of rotation moves posteriorly. With these smaller defects the degree

of movement during function is less as additional maxillary structures remain for support and

stability. With anterior resection of the maxilla, the axis of rotation is located along the posterior

margin of the defect. The anterior lip margin of the prosthesis will exhibit the greatest

movement.

Retention, stability and support:Retention is the ability of the prosthesis to resist vertical tissue away displacing forces.

Stability is the ability of the prosthesis to withstand the horizontal forces of dislodgment, support

is the resistance to the vertical stress (tissue – ward movement) during mastication and

swallowing. In most cases acceptable retention, stability and support can be gained from the

residual palatal structures by engaging the defect appropriately.

Remaining palatal structures:The arch form, the amount of palatal shelf remaining and the character of the residual

alveolar ridge influence stability and support. The palatal shelf is located perpendicular to the

direction of occlusal stress and it provides considerable support during function. A square or

ovoid arch will exhibit relatively more palatal shelf area following a total maxillectomy. The

reduced area and undesirable angulation of the palatal shelf in tapering arches does not provide

as much support during mastication.


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The height and contour of the residual alveolar ridge and the depth of the sulci are

important considerations. A healthy well formed ridge with extensive sulci will enhance stability

and support.

The defect:Acceptable retention can be gained by engaging key areas within the defect. The edentulous

patient should know that the prosthesis will exhibit considerable movement during function.

Engagement of the skin graft and scar band formed at the skin graft mucosal junction will

improve retention. Since, the lateral portion of the obturator exhibits the greatest degree of

movement, retention can be improved by appropriate obturator – tissue contact superior

laterally.

Additional retention may be gained by extending the prosthesis along the nasal surface of

the soft palate. Flexible materials are some time used in edentulous patients but they have short

time of service, fungal contamination and poor adjustability. Engagement of key portions of the

defect can improve support and stability. Stability is enhanced by engaging the super lateral

portion of the defect and some times the medial margin (when lined with keratinized

epithelium). Support can be obtained from the oral side of the skin graft – mucosal junction

from the oral surface of the soft palate.

Technique of construction:1- Preliminary impression:

To record the remaining maxillary structures and the useful portion of the defect, an

edentulous soft metal tray is altered. The medial and anterior undercuts are blocked – out as

these undercuts are not engaged by the prosthesis. Adhesive is applied to the tray. Hydrocolloid

mix is loaded in the tray, impression material is placed laterally to record the lateral

configuration of the defect. Before seating the tray, impression material is injected into the

posterior and lateral undercuts. Accurate diagnostic cast reproduces the usable undercuts, aidsin evaluating the degree of retention and stability.

2- Special tray:

Undesirable undercuts are blocked out on the diagnostic cast before constructing the

special tray (made of acrylic resin on a spacer). Extensions of the tray are verified in the mouth.

Inaccessible areas are checked with disclosing wax for possible overextension. Border molding of

the tray is carried out using modeling plastic. The palatal margins of the defect area is also

developed by border molding. Border will ensure the stability of the tray which is a key factor in

obtaining an accurate reproduction of the borders of the defect.

3- Final Impression:

Several perforations are made in the tray for escape of excess impression material that may

prevent correct of the tray. Adhesive is painted. Excess secretions are removed. The material isinjected into desirable undercut and the loaded tray is seated into position. The lips and cheeks

are manipulated and the patient is asked to do eccentric movements of the mandible. After

setting the tray is removed with a gentle teasing action.

A alternative impression technique: is suggested by making use of the surgical prosthesis.

First, do any necessary alterations if needed until the prosthesis is acceptable then apply a new

layer of tissues conditioning material.

4- Recording Jaw relation:

On the master cast construct record bases. if the defect is large and stability and support

are difficult to obtain a conventional record base, construct the permanent bas from the master

cast. if stability and support are adequate conventional self curing base is made on the master

cast (after blocking of undercuts with clay to protect the cast).


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Vertical dimension of occlusion is recorded as usual. If there is trismus the vertical

dimension of occlusion is reduced to allow passage of the bolus of food between the denture

teeth.

Centric relation is then recorded with recording medium. Care must be exercised to ensure

that the record base is not displaced during registration. Even in the relatively stable bases,

pressure on the defect side will cause superior displacement into the defect and compromise theaccuracy of the recording. Soft wax, zinc – oxide or plaster are preferred as recording media.

5- Occlusal schemes:

Non anatomic teeth are used and set following contours established by the wax rims and

anatomic landmarks. They are set in centric occlusion and adjusted to eliminate lateral

deflective occlusal contact.

6- Try in.

7- Processing, delivery and follow up:

The waxed up obturator is processed in heat – cured acrylic resin. To gain retention use a

soft silicone material for the obturator segment of the prosthesis to engage the undercuts more

aggressively.

Superior surface of the obturator should be slightly convex and well polished. Slapprojections should be rounded and polished. Polishing improves cleansibility and results in less

friction at the prosthesis – tissue interface during functional movements. Pressure indicator

paste is used to delineate areas of excessive tissue displacement.

Home care instructions:

Most maxillary obturator require rebasing within the first year of delivery because of

further organization of the defect with dimensional changes.

Edentulous Patients with Partial Maxillectomy DefectsIn patients with partial maxillectomy defects, more of the hard palate remains and thus the

prosthesis has more stability and support. Retention may be compromised because access and

use of the defect may be impaired. The defect should be utilized as mush as feasible to enhance

the function. Soft silicone material are useful.

Dentulous Patients with Total Maxillectomy DefectsBetter prognosis with the presence of teeth which assist retention, support and stability.

Treatment concepts:a) Location of the defect:

Surgical resection usually includes the distal portion of the maxilla and rarely does a distalabutment remains. The extent of the resection anteriorly varies. Thus Kennedy class II partial

denture with extensive lever arm is that required.

b) Movement of the prosthesis:

The degree of movement of class II partial denture is dependent on the quality of the ridge

and palate and the ability to utilize the support from both the edentulous segment and teeth.

With resection of the maxilla mucosal and bony support are compromised. Hence the defect

must be used to minimize the movement trying to reduce the stress on the abutment teeth.

c) Arch form:

Square or ovoid arches posses more bearing surface perpendicular to occlusal stresses

resulting in more stable prosthesis during function. Tapering arch forms provide less palatal

shelf area and thus support is compromised.

d) Teeth:


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Preservation of the remaining teeth is important for retention. Partial denture design must

anticipate and accommodate to the movements of the prosthesis during function without

exerting pathologic stresses on teeth. Maximum retention, stability and support must be

obtained from the use of the defect.

e) Partial denture design:

Diagnostic casts are surveyed to locate undercuts, guiding planes and select the path ofinsertion. Often a compound path of insertion must be employed to use the undercut in the

defect. Major connectors must be rigid, occlusal rests must direct occlusal forces along the long

axis of the teeth, and guide planes must be designed to facilitate stability and bracing.

Retention should be within the physiologic limits of the periodontal ligament and maximum

support must be gained from the residual soft tissues. A tooth closely adjacent to the anterior

margin of the defect must have a rest and a retainer, if adequate retention is to achieved. the

anterior occlusal rest and retainer ensures oriention of the prosthesis.

If this concept is not employed the prosthesis will tend to rotate out of the retentive area is

not employed the prosthesis will tend to rotate out of the retentive area posteriorly. Often the

bony support for the tooth adjacent to the defect is questionable and does not permit its use as

abutment. Other adjacent tooth will have to be used.The fulcrum line is determined by the position of the occlusal, incisal or cingulum rests.

Since there is no cross – arch reciprocation of either buccal or lingual retention, this partial

denture may be viewed as a unilateral partial denture. For this reason both buccal and lingual

retentive arms may be considered to obtain cross – tooth retention and reciprocation.

Prosthetic procedures:1- Treatment plane.

2- Required restorative procedures.

3- Mouth preparation.

4- Master impression to construct the partial denture frame work.

Prior to impression making, the medial palatal undercut in the defect is blocked out with

gauze, however, the lateral portion of the defect should be recorded with the impression as these

contours will be necessary to fabricate the tray for the altered cast impression. The master cast is

made and the metal frame – work fabricated. The obturator portion should be of acrylic r

Maxillofacial Notes Dr.mahmoud Ramadan

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