Section Four
Maxillofacial
Prosthetics
(MFP) • Introduction to Maxillofacial
Prosthodontics
Types of Maxillofacial Defects
Types of Maxillofacial Prosthesis
Materials Used in
Maxillofacial Prosthetics
Chapter 35
Introduction to
Maxillofacial Prosthodontics
Introduction
Classification of
Maxillofacial Prosthesis
Introduction to Maxillofacial
Prosthodontics
INTRODUCTION as it is the God-given right of every human being to
appear human.
Maxillofacial prosthodontia is the art and science of
functional, or cosmetic reconstruction by means of CLASSIFICATION OF
non-living substitutes for those regions in the maxilla, MAXILLOFACIAL PROSTHESES
mandible, and face that are missing or defective
because of surgical intervention, trauma, pathology, or
A wide variety of maxillofacial prostheses are being
fabricated in practice. Based on the location, use,
developmental or congenital malformation. Despite
remarkable advances in surgical and area of restoration, maxillofacial prostheses can
management of oral and facial defects, many such be classified as follows:
defects, especially those involving the eyes and ears,
Maxillofacial prosthesis
cannot be satisfactorily repaired by plastic surgery
alone. Also, the increased life span of the affected Prosthesis:
people and the growing awareness of health care Intraoral
services place additional challenges on maxillofacial — Maxillary
prosthodontists. Extensive research and Congenital
developments in the field of materials used for these – Cleft lip
prostheses permit us to restore large number of such – Cleft palate
defects. Acquired
A prosthodontist well versed with the techniques – Total maxillectomy
and materials, alongwith the biologic aspects of the • Complete dentures
conditions, should be able to restore the patient’s • Partial dentures
smile back to normal. • Obturators
This text provides the student of a dental school • Speech aids
with the basic and practical idea on the recognition • Implants
and management of wide variety of defects. Basic – For partial maxillectomy
information relevant to biologic sciences is reviewed • Complete dentures
alongwith the different types of prostheses available • Partial dentures
depending on the clinical situation. Various — Mandibular
techniques and materials available also have been Congenital
discussed for use in intraoral or extraoral devices. – Cleft lip
Many illustrations and diagnosis have been – Early feeding devices
incorporated to help describe these techniques and – Surgical
appliances. – Orthodontic
It is our sincere attempt to help the students – Prosthodontic
resolve large numbers of such people to society, – Fixed partial dentures
– Complete dentures — Lip and cheek prosthesis
– Implants Treatment supplements:
• Acquired • Radiotherapy supplements
– Complete dentures — Stents
– Partial dentures — Splints
– Flange prosthesis — Shields
– Mandibular exercisers — Carriers
– Implants — Positioners
• Extraoral — Radiation appliances
— Auricular prosthesis • Surgical supplements
— Ocular prosthesis — Prosthetic dressings
— Orbital prosthesis — Surgical splints
— Nasal prosthesis — Surgical obturators
— Composite prosthesis • Chemotherapeutic supplements.
Chapter 36
Types of Maxillofacial Defects
Maxillary Defects
Velo-pharyngeal Defects
Extraoral Defects
Traumatic Defects
Types of
Maxillofacial Defects
MAXILLARY DEFECTS Cleft lip and cleft palate Cleft lip occurs due to
improper fusion between the fronto-nasal and
In the following section we shall discuss about the maxillary process. If this occurs on one side it leads
types of maxillary defects, prosthetic impli-cations to a unilateral cleft. If it occurs on both sides, it leads
of their surgical management and the restoration of to a bilateral cleft. In Mohr’s syndrome, a median
these defects with modified partial or complete (midline) cleft lip is seen (Fig. 36.1).
dentures.
Patients with maxillary defects will have diffi-
culties in mastication, speech and deglutition. The
aim of a maxillofacial prosthesis should be to restore
the normal physiological function in these patients.
The fabrication of various prosthesis used in the
management of these defects are described in the
next chapter.
Figs 36.1a and b: (a) Bilateral cleft lip
Types of Maxillary Defects (b) Single median cleft lip
Maxillary defects can be broadly classified as Aetiology includes infections, drugs (pheny-toin,
follows: ethanol and barbiturates), poor diet, and hormonal
— Congenital imbalance in the first trimester and genetic factors
– Cleft lip (13 trisomy Ptau’s syndrome).
– Cleft palate Cleft lip with or without cleft plate occurs in a
— Acquired ratio of 1:1000. It is twice as common in males when
– Total maxillectomy compared to females. It can either be unilateral or
– Partial maxillectomy bilateral. Unilateral cleft lip is more common on the
In the following section, we shall discuss about left side.
the clinical considerations of common maxillary
defects in detail. Classification of Clefts
Classification based on the extent of the defect:
Congenital Maxillary Defects
Clefts can be classified into three types under this
The most common congenital maxillary defects category,
include cleft lip and cleft palate. Other defects like Class I : Cleft lip with cleft alveolus (primary
sub-mucous cleft palate, Pierre Robin syn-drome, palate) (Fig. 36.2).
hemifacial microsomia are treated using the same Class II : Cleft of hard and soft palate (secondary
basic principles followed in the management of cleft palate) (Fig. 36.3).
lip/palate cases. Class III: Combination of I and II (Fig. 36.4)
fig 36.2 fig 36.5
Fig 36.3
Fig 36.6
Fig 36.4
Fig 36.7
Veau’s Classification of Cleft Palate
Veau (1922) classified cleft palate into four
types mainly,
Class I: Cleft involving the soft palate. It can
also be a sub-mucous cleft, which appears
normal (Fig. 36.5).
Class II: A midline cleft involving the bone,
present only on the posterior part of the palate
(Fig. 36.6).
Class III: A unilateral cleft extending along the
Fig 36.8
mid-palatine suture and a suture between pre-
maxilla and palatine shelf (Fig. 36.7).
Class IV: A unilateral cleft extending along the between pre-maxilla and palatine shelf (Fig.
mid-palatine suture and both the sutures 36.8).
Anterior cleft is associated with defective development of the primary palate. It occurs due to
mesenchymal deficiency. Posterior cleft occurs due to defective development of the secondary palate
(due to improper fusion of the palatine shelves).
For young patients, a permanent prosthesis should not be provided. Instead, a well fitting interim
prosthesis should be provided. This interim prosthesis is replaced with a permanent one at around 25
years of age. A removable interim partial denture is preferred over a fixed prosthesis because it is
more aesthetic in repro-ducing gingival contour, and it also helps to cover an unaesthetic residual
alveolar cleft. The most
important concern in the restoration of these cases is establishment of aesthetics.
One should remember that most of these patients would have had complete surgical management
of the defect before they report to a prosthodontist. Patients treated with bone grafts to fill the alveolar
clefts are easy to manage compared to patients with open clefts (Fig. 36.9).
Figs 36.9a and b: (a) Alveolar cleft repaired with a bone graft (b) Open or ungrafted alveolar cleft
Posterior cleft palate cases are usually treated using speech bulbs and palatal lift prosthesis. These
maxillofacial prosthetic appliances are usually combined to the conventional prosthesis (RPD, CD,
FPD) that may be required for the patient.
Design Considerations in the Placement of Implants for a Cleft Lip, Cleft Palate Patient
Usually the permanent maxillary lateral incisor will be absent in such cases. The missing tooth (lateral
incisor) can be restored using a fixed par-tial denture, a removable partial denture, Mary-land bridge
or an implant supported single tooth replacement. Implants have the following advantages:
No abutment tooth preparation is required.
It helps to avoid excessive load on the natural teeth.
It helps to transfer the forces to the grafted bone. (This helps to reduce the resorption of
the graft).
Acquired Maxillary Defects
Most acquired maxillary defects occur due to surgical resection of tumours. Benign lesions
require a smaller resection and are easy to res-tore. Whereas malignant tumours require
exten-sive resection, which are very difficult to restore.
Common tumours of this region are epidermoid carcinoma (mostly arising from the
maxillary sinus), salivary gland tumours (pleomorphic adenoma, adenoid cystic carcinoma,
mucoepi-dermoid carcinoma and adenocarcinoma), malig-nant mesenchymal tumours
(lymphosarcoma, rhabdomyosarcoma, chondrosarcoma, neuro-fibrosarcoma, angiosarcoma
and osteosarcoma) and benign mesenchymal tumours (fibroma, hemangioma,
angioleomyoma, angioblastoma, fibrolipoma and myxoma) . Tumours of dental origin can
also occur in the palate.
Other non-neoplastic lesions like midline granuloma, Wegener’s granulomatosis, Mucor-
mycosis, and aspergillosis may also require surgical resection in the course of treatment.
One other major cause for an acquired maxillary defect is trauma. Since one cannot predict
the nature and extent of the defect produced by trauma it has been discussed separately.
Types of Acquired Maxillary Defects
Acquired maxillary defects are usually classified based on their extent. If both the maxillae
are resected, the defect is considered as total maxillectomy. Resection of one or a part of the
maxilla or palate is considered as Partial Maxillectomy.
Aramany proposed a classification of partial maxillary defects based on their extent.
Class I: It is a unilateral defect involving one half of the arch and the adjacent palatine
shelf. The defect extends to the midline (all the teeth in that side of the arch are missing)
(Fig. 36.10).
Fig. 36.10 Fig. 36.13
• Class II: It is a unilateral defect involving one • Class V: It is a bilateral posterior defect (teeth
side of the arch posterior to the canine (teeth anterior to the second premolar are present)
posterior to the canine are absent) (Fig. 36.11). (Fig. 36.14).
Fig. 36.11 Fig. 36.14
• Class III: It is a defect involving the centre of • Class VI: It is a bilateral anterior defect ((teeth
the palatine shelves (all the teeth are present) anterior to the second premolar are absent).
(Fig. 36.12). (Fig. 36.15).
Fig. 36.12 Fig. 36.15
• Class IV: It is a bilateral defect involving one
side of the arch along with the entire pre- Defects acquired due to surgical resection can
maxilla (all anteriors along with the posteriors be restored with obturators. Additional details are
of one side are missing) (Fig. 36.13). discussed in the next chapter.
